Elevated B-type natriuretic peptide without volume overload in a left ventricular assist device patient with a subdural hematoma.

We report a case of elevated B-type natriuretic peptide (BNP) without volume overload in a left ventricular assist device patient with a subdural hematoma and cerebral salt wasting syndrome suggesting a noncardiac etiology for BNP elevation.

An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry.

BACKGROUND: Prior studies on chronic systolic heart failure (HF) have demonstrated that body mass index (BMI) is inversely associated with mortality, the so-called obesity paradox. The aim of this study was to determine whether BMI influences the mortality risk in acute decompensated HF, a subject not previously studied. METHODS: The Acute Decompensated Heart Failure National Registry was analyzed for acute HF hospitalizations in 263 hospitals in the United States from October 2001 through December 2004. Patients with documented height and weight were divided into BMI (measured in kilograms per square meter) quartiles. Inhospital mortality by BMI quartile for all the patients and for those with reduced (n = 43,255) and preserved (n = 37,901) systolic function was assessed. RESULTS: Body mass index quartiles in the 108,927 hospitalizations were QI (16.0-23.6 kg/m2), QII (23.7-27.7 kg/m2), QIII (27.8-33.3 kg/m2), and QIV (33.4-60.0 kg/m2). Patients in the higher BMI quartiles were younger, had more diabetes, and had a higher left ventricular ejection fraction. Inhospital mortality rates decreased in a near-linear fashion across successively higher BMI quartiles. After adjustments for age, sex, blood urea nitrogen, blood pressure, creatinine, sodium, heart rate, and dyspnea at rest, BMI quartile still predicted mortality risk. For every 5-U increase in BMI, the odds of risk-adjusted mortality was 10% lower (95% CI 0.88-0.93, P < .0001). CONCLUSIONS: In this cohort of hospitalized patients with HF, higher BMI was associated with lower inhospital mortality risk. The relationship between BMI and adverse outcomes in HF appears to be complex and deserving of further study.

Successful multi-vessel percutaneous coronary intervention with bivalirudin in a patient with severe hemophilia A: a case report and review of literature.

We describe a 64-year-old male with severe hemophilia A (factor VIII-dependent), acute myocardial infarction (MI) and congestive heart failure (CHF) who underwent successful multi-vessel percutaneous coronary intervention (PCI). The patient was administered factor VIII transfusion to maintain activity levels between 60-80%. Anticoagulation during the PCI procedure was maintained with the direct thrombin inhibitor, bivalirudin. There were no procedural complications and the patient was discharged home the following day. These results suggest that bivalirudin may be used effectively in patients at very high risk of bleeding with enhanced procedural safety.

Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study.

BACKGROUND: Cardiac retransplantation is a controversial procedure due to the disparity between donor heart demand and supply. METHODS: Of 7,290 patients undergoing primary cardiac transplantation between January 1990 and December 1999 at 42 institutions contributing to the Cardiac Transplant Research Database (CTRD), 106 patients later underwent a second and 1 patient a third cardiac transplant procedure. RESULTS: The actuarial freedom from retransplantation was 99.2% and 96.8% at 1 and 10 years, respectively. Reasons for retransplantation included early graft failure (n = 34), acute cardiac rejection (n = 15), coronary allograft vasculopathy (CAV, n = 39), non-specific graft failure (n = 7), and miscellaneous (n = 10). The only risk factor associated with retransplantation was younger age, reflecting the policy of preferential retransplantation of younger patients. Survival after retransplantation was inferior to that after primary transplantation (56% and 38% at 1 and 5 years, respectively). Risk factors associated with death after retransplantation included retransplantation for acute rejection (p = 0.0005), retransplantation for early graft failure (p = 0.03), and use of a female donor (p = 0.005). Survival after retransplantation for acute rejection was poorest (32% and 8% at 1 and 5 years, respectively) followed by retransplantation for early graft failure (50% and 39% at 1 and 5 years, respectively). Survival after retransplantation for CAV has steadily improved with successive eras. CONCLUSIONS: The results of retransplantation for acute rejection and early graft failure are poor enough to suggest that this option is not advisable. However, retransplantation for CAV is currently associated with satisfactory survival and should continue to be offered to selected patients.

Cardiologia en la ruralia / Cardiology in rural areas

Basados en una experiencia personal al ,antener una consulta cardiológica en al localidad de arroyo (Puerto Rico), analiza,os la necesidad del estableci,iento de un servicio de este tipo en el ,edio rura, con los siste,as tecnológico que ello conlleva. Del estudio de los datos obtenidos a partir de los historiales clínicos, he,os extraido la infor,ación sobre la asistencia ,edia de los pacientes a esta consulta y las pruebas diagnósticas y procedi,ientos terapéuticos realizados a los ,is,os. En general, se constató, que no hubo un segui,iento prolongado de los enfer,os; y al ,is,o tie,po, una baja utilización de los ,edios de diagnóstico. Co,o conclusión establece,os: que la existência de clínicas cardiológicas en el ,edio rural es razonable, sie,pre que su función se ,era,ente consultiva. Sin e,bargo, no considera,os necesario que las poblaciones del tipo de la estudiada, requieran contar con ,edios de diagnóstico cardiológico de alta tecnología

El trasplante cardíaco: desarrollo y madurez del programa en la Universidad del Sur de la Florida y el Hospital General de Tampa / Heart transplantation: development and maturity of the program at the University of South Florida and the General Hospital of Tampa

El trasplante cardíaco ha evolucionado de una terapia experimental a una terapia establecida que prolonga la supervivencia en pacientes con fallo cardíaco severo. Decidimos proceder con tal programa en el 1984 y luego de más de un año de desarrollo organizativo se procedió con nuestro primer trasplante cardíaco en junio de 1985. Desde entonces hasta enero de 1989 hemos realizado 50 transplantes cardíacos de los cuales 37 pacientes sobreviveron. La supervivencia calculada en un año es del 78% y en dos años 72%, lo cual es aproximadamente dos veces la superviviencia de pacientes con fallo cardíaco severo tratados por métodos convencionales. La maíoria de estos pacientes desarrollan infecciones severas o rechazo del corazón trasplantado, ambas complicaciones potencialmente letales, pero controlables con terapia médica intensa. El gran costo económico y emocional de esta terapia limita su uso. El reciente endoso que hemos recibido de la agencia federal "Medicare" provee a los residentes del sureste de los Estados Unidos de Norte América y del Caribe con este recurso adicional para servicios cardiovasculares

DIASTOLIC OPENING OF THE AORTIC VALVE (AV) IN A CASE OF AORTIC INSUFFICIENCY DUE TO AV FENESTRATION.

A patient with severe aortic insufficiency due to fenestration of the non-coronary aortic valve leaflet is described. A preoperative echocardiogram demonstrated early closure of the mitral valve and early diastolic separation of the aortic valve leaflets. These findings disappeared after partial surgical correction and subsequent hemodynamic improvement. Premature opening of the aortic valve is common in severe aortic insufficiency.