Predicting Short- and Long-Term Outcomes in Adult Heart Transplantation: Clinical Utility of MELD-XI Score.

BACKGROUND: Model for End-Stage Liver Disease scoring system excluding international normalized ratio (MELD-XI) has been related with worse outcomes after heart transplantation (HT). However, according to standards in prognostic models research, before implementing a risk score for daily clinical decision-making, its performance and impact on clinical practice/outcomes should be evaluated. The aim of this study was to evaluate the ability of the MELD-XI score to predict outcomes in daily clinical practice. MATERIAL AND METHODS: We retrospectively reviewed 190 consecutive adults undergoing HT between 2005-2015. Patients were stratified into low (MELD-XI <12) and high (MELD-XI ≥12) risk cohorts. Mortality rates at 30 days and 1 year were compared between MELD-XI groups. MELD-XI ability to predict 1-year mortality was assessed by the area under the receiver operating curve (AUC) and compared to that of bilirubin, creatinine, and pulmonary vascular resistance (PVR). RESULTS: Mortality rates at 30 days and 1 year were similar between groups (8% vs 13%; P = .28 and 21% vs 29%; P = .21, respectively). MELD-XI ability to predict 1-year mortality was poor and similar to that of bilirubin, creatinine, and PVR (0.51 vs 0.47 vs 0.50 vs 0.50, respectively). CONCLUSIONS: MELD-XI score utility in HT clinical decision-making is scarce since its discrimination ability is poor and similar to other simple prognostic variables.

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%).

Effect of different pharmacologic agents to reverse severe pulmonary hypertension among end-stage heart failure patients.

OBJECTIVE: The goal of this study was to analyze the hemodynamic responses during vasoreactivity tests among candidates for heart transplantation who displayed severe pulmonary hypertension seeking to identify risk markers of nonresponse to the test. MATERIALS AND METHODS: In this observational retrospective study we evaluated demographic, clinical, echocardiographic, and hemodynamic variables. The target hemodynamic goal in the vasoreactivity test was to achieve a transpulmonary gradient (TPG) <12 mm Hg and/or pulmonary vascular resistances (PVR) <2.5 Wood Units (WU). RESULTS: We analyzed medical records from 79 patients. Inotropes (dopamine or dobutamine) were used to treat 33 patients, nonselective vasodilators (nitroglycerin or sodium nitroprusside) were used in 22 patients, and prostacyclin (PC) was used in 24 patients. The study observed a significant decrease in pulmonary pressures, PVR, and TPG, with increased cardiac output (CO) compared with baseline hemodynamics in all groups. No significant differences were observed between agents except for an increase in CO, which was greater in the PC group. Also, 49.4% of patients were considered responders to the vasoreactivity test without significant differences between groups. Risk markers for absence of a response to the vasoreactivity test were a CO <2.5 L/min (odds ratio [OR] = 2.1; confidence interval [CI] 95%, 1.1-3.9; P = .035) and a PVR >6 WU (OR = 3.7; CI 95%, 1.8-7.6; P < .001) in the baseline hemodynamic study. CONCLUSIONS: Inotropes, nonselective vasodilators, and prostacyclin produced effective vasodilator responses in the pulmonary vascular bed during the vasoreactivity test. The presence of a baseline high PVR or a low CO were predictors of nonresponse to the test.

[Sildenafil as a substitute for subcutaneous prostacyclin in pulmonary hypertension]. / Sildenafilo como sustituto de prostaciclina subcutánea en la hepertensión pulmonar.

Subcutaneous prostacyclin (treprostinil) is an effective short-term treatment for pulmonary hypertension. The most frequently described adverse effect-pain in the area of injection-rarely requires that treatment be withdrawn. Sildenafil is a selective fosfodiesterase-5 inhibitor with pulmonary vasodilating effects. We describe the use of sildenafil as a substitute for treprostinil in a patient with pulmonary hypertension associated with lupus erythematosus. Treatment with treprostinil was discontinued due to uncontrollable abdominal pain.

Sildenafilo como sustituto de prostaciclina subcutánea en la hipertensión pulmonar / Sildenafil as a substitute for subcutaneous prostacyclin in pulmonary hypertension

No disponible

[Incidence and dynamic behavior of spontaneous echocardiographic contrast and atrial thrombi in the transplanted heart]. / Incidencia y comportamiento dinámico del contraste ecocardiográfico espontáneo y del trombo auricular en el corazón trasplantado.

BACKGROUND: Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations with subsequent thrombotic risk. Therefore the aim of this study was to analyze the prevalence and evolution of spontaneous echocardiography, atrial thrombi and embolic events. PATIENTS AND METHOD: 52 consecutive transplanted patients were analyzed with transesophageal echocardiography and hemodynamic studies performed at 15 days and one year after transplantation. RESULTS: Spontaneous echocardiography contrast was present in 27 patients (52%). Ten atrial thrombi were observed (19.2%), 9 with spontaneous echocardiography contrast. Six atrial thrombi appeared on day 15 and 4 after one year (with spontaneous echocardiography contrast on the previous study). Using multiple logistic regression analysis left atrial size was the only independent predictor factor for spontaneous echocardiography contrast (OR = 1.27; 95% CI, 1.09-1.54) and was an important predictor factor of atrial thrombi formation (OR = 1.19; 95% CI, 1.04-1.42). Likewise, the main predictor of atrial thrombi was the presence of spontaneous echocardiography contrast (OR = 116; 95% CI, 8.4-999). The hemodynamic pattern did not predict either the presence of spontaneous echocardiography contrast or atrial thrombi. The global incidence of embolic events was 4% less than previously described. CONCLUSIONS: The incidence of atrial thrombi and spontaneous echocardiographic contrast after standard orthotopic heart transplantation was 19.2% and 52%, respectively. An enlarged atrium and/or spontaneous echocardiography contrast was found to increase the risk of atrial thrombi. Considering the dynamic nature of atrial thrombi formation, periodical transesophageal echocardiography studies are recommended after heart transplantation.

[Mycotic aneurysm caused by Aspergillus of the aortic suture line after heart transplantation]. / Aneurisma micótico por Aspergillus en la línea de sutura aórtica tras el trasplante cardíaco.

The first case of mycotic aneurysm of aorta by Aspergillus in a patient with heart transplantation is described, in which the infection was produced by direct surgical contamination of the aortic suture. The period of latency was of eight months. The unusualness of the case and its diagnostic difficulties, are is commented.

Manejo del enfermo con miocardiopatía dilatada y miocarditis / Management of the patient with dilated myocardiopathy and myocarditis

La miocardiopatía dilatada (MCD) es una enfermedad intrínseca del miocardio, caracterizada por la dilatación del ventrículo izquierdo o de ambos ventrículos, así como por la disminución de su contractilidad. Es más frecuente en varones en la edad media de la vida, pero debido a que en las fases iniciales suele cursar de forma asintomática, su incidencia puede estar infraestimada. Se han identificado múltiples etiologías causantes de MCD, y todo apunta a que diversos factores pueden influir conjuntamente en producirla. Con frecuencia no se encuentra el agente causal y entonces se denomina MCD idiopática. Su presentación clínica es muy variada, pero la manifestación más frecuente es la insuficiencia cardíaca (IC), que se agrava conforme evoluciona la enfermedad.El manejo de los pacientes con MCD consiste en retrasar la progresión hacia la IC y disminuir la morbimortalidad.La miocarditis es un proceso inflamatorio no isquémico del miocardio, debido a un amplio y heterogéneo grupo de agentes etiológicos con variada distribución geográfica, lo que afecta a la incidencia y prevalencia de la enfermedad. Existe una fase inicial de agresión al miocardio, que suele seguirse de curación o de una segunda fase de inflamación crónica mediada por mecanismos autoinmunes, asociados o no a la persistencia del agente causal. La clínica varía desde la curación completa hasta la evolución hacia MCD. Su tratamiento es sintomático incluyendo el manejo y prevención de las complicaciones. Actualmente se investiga con la terapia inmunosupresora, basándose en la posible perpetuación del daño miocárdico por mecanismos autoinmunes. (AU)

[An anomalous origin of the left coronary artery associated with a right coronary spasm as the cause of angina and presyncope]. / Origen anómalo de la arteria coronaria izquierda asociado a espasmo de la coronaria derecha como causa de angina y presíncope.

We describe the rare association of angina at effort and presyncope in a young patient with an anomalous origin of left coronary artery and associated coronary spasm in the normal right coronary artery. The patient did well under calcium channel blocker therapy after seven years of follow-up, which is in contrast with the usual recommended management of these patients.

[Pulmonary arterial hypertension and heart transplantation: hemodynamic evolution and survival]. / Hipertensión arterial pulmonary y trasplante cardíaco: evolución hemodinámica y supervivencia.

BACKGROUND: Patients with chronic heart failure and pulmonary arterial hypertension are at risk of developing fatal right graft failure after transplantation, and there is no agreement about the limit of pulmonary vascular resistance for such risk. PURPOSE: To study what the impact is on the survival of a degree of pulmonary hypertension not considered to be an exclusion for orthotopic heart transplantation and to analyze the hemodynamic profile in the minor circuit after surgery. PATIENTS AND METHODS: We studied a group of 69 patients consecutively transplanted and with followup of at least one year. Patients were classified in two groups depending on the hemodynamic factors previous to transplant: group A (without pulmonary hypertension, 22 patients) and group B (with pulmonary hypertension, 47 patients). After heart transplantation we analyzed the causes of mortality and the evolution hemodynamic profile in both groups. RESULTS: In the group of patients with pulmonary hypertension there was an increase in perioperative mortality due to graft failure (p < 0.05), although at the end of the first year, the survival rate was similar in both groups. After heart transplantation, the level of pulmonary pressures dropped in the same group, but at the end of the first year, a 17% of the patients maintains some criteria of pulmonary hypertension. CONCLUSIONS: Our results confirm that degrees of pulmonary hypertension classically not considered as an exclusion for orthotopic heart transplantation were associated with an increase mortality by graft failure. The majority of survivors after heart transplantation normalize pulmonary pressures at one year of transplantation.

New technique for right heart catheterization using a Mullins' sheath.

A new technique for right heart catheterization using a Mullins' sheath is described. This device allows a Swan-Ganz catheter to reach pulmonary artery position easily and permits simultaneous pressure recordings in right heart chambers, thus avoiding a double venous puncture and two catheters. This new technique, its indications, and our experience in 29 patients are described. It is most useful in patients with severe pulmonary hypertension and in those conditions in which accurate right heart pressure measurements are needed.

[Severe poisoning with digitalis treated by the administration of anti-digoxin antibodies]. / Intoxicación grave por digital corregida por la administración de anticuerpos antidigoxina.

A case report of severe digitalis poisoning in a patient with prosthetic heart valve is presented. He complained of nausea, vomiting, drowsiness, temporal disorientation and lethargy. The electrocardiogram showed idioventricular rhythm, and plasma levels of digoxin were 6.78 ng/ml. Predisposing factors por digitalis poisoning were prerenal failure and concomitant quinidine therapy. Treatment with digoxin-immune antibody fragments (FAB) promptly lead to abolition of the ventricular arrhythmia and disappearance of every clinical symptoms in hours. Plasma digoxin levels showed a steep decrease until normal values at the fifth day. The favourable course of either clinical and electrocardiographic response to IV administration of FAB are discussed, stressing the fact of the high morbidity of digitalis poisoning in opposition to the relative safety of Fabs use in its therapy.

Spontaneous left atrial haematoma.

We present a woman with paroxysmal atrial fibrillation and a mass in the left atrium. Cross-sectional echocardiography defined the lesion as cystic, while magnetic resonance imaging depicted it as a solid mass with areas of focal bleeding. Surgical resection showed a partially organized haematoma within the left atrial wall. The patient did well after surgery, although atrial fibrillation recurred. The presence of an atrial haematoma is rare, specially when spontaneous, and we stress the usefulness of magnetic resonance in reaching an aetiologic diagnosis.