Clinical evolution of heart transplantation in patients with previous valvular cardiomyopathy.

OBJECTIVE: Heart transplantation (HT) due to valvular cardiomyopathy is rare, namely, about 3% of cases in the Registry of the International Society for Heart and Lung Transplantation (ISHLT). Usually, these patients present some risk factors such as previous valvular operations and pulmonary hypertension. Since there are few studies in the literature, we retrospectively analyzed our early and long-term results. MATERIALS AND METHODS: We studied our experience in 22 HT cases for valvular cardiomyopathy (9.3% of our total experience), namely, 12 men and 10 women, of overall mean age of 52.6 +/- 10 years. Five patients had mitral; 8, aortic; and 1, tricuspid valve disease; 7 had double valve disease and 1, triple valve disease. Nineteen patients (87%) had been operated previously between 1 and 4 times. The mean ejection fraction was 23% +/- 7.3% and the mean New York Heart Association (NYHA) functional class was 3.7. Fifty-three percent of the patients had pulmonary hypertension. Two patients were operated as an emergency "O." We used the standard HT technique. RESULTS: Four patients (18%) were reoperated due to hemorrhage. The hospital mortality was 2 cases (9%). Another patients (9%) died on follow-up due to cardiac allograft vasculopathy. All surviving patients have been followed to the end of 2006. The mean follow-up has been 72 +/- 53 months. They are functional class I or II. CONCLUSIONS: HT for this indication was more frequent in our experience than in the Registry of the ISHLT. The immediate and long-term results were good, with an 82% mean survival at 6 years. HT can be a good treatment for patients with valvular cardiomyopathy and bad ventricular function and/or multiple valvular reoperations.

Trombosis venosa renal en recién nacida portadora de la mutación G20210A del gen de la protombina / Renal venous thrombosis in a neonate carrying the G20210a mutation of the prothrombin gene

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[Congenital renal abnormalities in neonates with fetal vesicoureteral reflux. Detection by 99m-technetium(m)-dimercaptosuccinic acid renal scintigraphy]. / Anomalías renales congénitas en neonatos con reflujo vesicoureteral fetal. Detección con gammagrafía renal-99mTc-DMSA.

BACKGROUND: "Fetal" vesicoureteral reflux (VUR) is characterized by predominance among males, high grade reflux and renal parenchymal abnormalities, indicating an association between sterile VUR and kidney lesions. OBJECTIVES: To determine, using technetium99m-dimercaptosuccinic acid (99mTc-DMSA) renal scan, the incidence of congenital renal abnormalities in infants with sterile VUR detected during the postnatal evaluation of prenatal hydronephrosis or sibling reflux screening and to speculate on the mechanisms of these lesions. METHODS: We retrospectively reviewed the DMSA renal scans of infants with VUR without a history of urinary tract infection (UTI). DMSA differential uptake less than or equal to 40% or cortical defects were considered as renal abnormalities. The findings were correlated with those of postnatal renal ultrasonography. RESULTS: Eighteen patients (15 boys and 3 girls) were included with VUR grade V, IV, III and II in 5, 10, 6 and 6, respectively, of the 36 renal units. DMSA revealed parenchymal abnormalities in 50% (9/18) of the patients and in 33% (9/27) of the renal units with VUR; most of the patients were boys (7 boys, 2 girls) with VUR grade V or IV (6/9; 66%). Postnatal ultrasonography showed low sensitivity (22%) to renal injury. CONCLUSIONS: In infants with sterile VUR, especially boys with high grade VUR, kidney abnormalities can already be present at birth suggesting a pathophysiology of renal injury independent of UTI. Moreover, renal parenchymal defects detected by DMSA renal scan are frequently not identified by postnatal renal ultrasound. Therefore, we recommend DMSA scanning in the initial evaluation of infants with VUR.

Anomalías renales congénitas en neonatos con reflujo vesicoureteral fetal. Detección con gammagrafía renal-99mTc-DMSA / Congenital renal abnormalities in neonates with fetal vesicoureteral reflux. Detection by 99M-technetiumM-Dimercaptosuccinic acid renal scintigraphy

Antecedentes: El reflujo vesicoureteral (RVU) "fetal" se caracteriza por una preponderancia masculina, reflujo de alto grado y anomalías parenquimatosas renales, estableciéndose una asociación entre RVU estéril y lesión renal. Objetivos Determinar, mediante gammagrafía renal con 99m tecnecio ácido dimercapto-succínico (99mTc-DMSA), la incidencia de anomalías renales congénitas en lactantes con RVU detectado posnatalmente por hidronefrosis prenatal o por cribado familiar, y especular sobre los mecanismos de acción de estas lesiones. Métodos: Se han revisado retrospectivamente las gammagrafías renales de lactantes con RVU y sin antecedentes de infección del tracto urinario (ITU), considerando anomalías renales: captación diferencial menor o igual al 40 por ciento o presencia de defectos corticales. Los hallazgos gammagráficos se han correlacionado con los de la ecografía posnatal. Resultados: Dieciocho pacientes cumplieron los criterios de inclusión; 15 niños y 3 niñas con RVU grado V, IV, III y II en 5, 10, 6 y 6 de las 36 unidades renales. La gammagrafía mostró alteraciones parenquimatosas en el 50 por ciento (9/18) de los pacientes y el 33 por ciento (9/27) de las unidades renales refluyentes; la mayoría fueron niños (7 niños, 2 niñas) con RVU de GV o GIV (6/9; 66 por ciento). La sensibilidad de la ecografía posnatal para detectar signos de lesión renal fue baja (22 por ciento). Conclusiones: Lactantes con RVU estéril, especialmente varones con RVU de alto grado, pueden presentar ya al nacimiento anomalías parenquimatosas renales, lo cual sugiere una etiopatogenia congénita de lesión renal independiente de la ITU. Estos defectos identificados por gammagrafía con frecuencia no son detectados en la ecografía posnatal. Por ambos motivos recomendamos la gammagrafía renal DMSA en la evaluación inicial de lactantes con RVU fetal (AU)

Acute myocardial infarction with cardiogenic shock: treatment with mechanical circulatory assistance and heart transplantation.

UNLABELLED: The mortality of cardiogenic shock (CS) after an acute myocardial infarction (AMI) still remains high. Thrombolysis, PTCA or CABG, when possible, can improve the results, but when all the treatments fail death is almost certain. OBJECTIVE: We investigate the use of the mechanical circulatory assistance (MCA) and heart transplantation (HT) to improve the adverse results in this irreversible situation. METHODS: Among 11 patients with irreversible CS after an AMI we used a MCA (Abiomed BVS-5000). After improvement and hemodynamic stabilization, we performed heart transplantation in 7 patients of mean age 52 years (35-60) including two women. The MCA was univentricular in 7 patients and biventricular in 4. Mean duration of the MCA was 5 days (1-12). RESULTS: Three patients died during the MCA: two due to cerebrovascular accidents and one multiorgan failure. Weaning was possible in one patient. Among Seven transplanted patients one died due to sepsis. Seven (64%) patients are long-term survivors. CONCLUSION: When all the treatments have failed for CS after an AMI, MCA may be used as a bridge to heart transplantation in a select group of patients where the procedure is not contraindicated. The long-term results of 64% survivors in our experience is satisfactory.

Sirolimus in heart transplantation: a single center initial experience.

Sirolimus (SRL) is a potent non-nephrotoxic immunosuppressant. In our unit, SRL was administered to 17 heart transplant (HT) recipients at 1770+/-1234 days' posttransplant surgery, for the following reasons: (1) calcineurin inhibitor (CI) withdrawal due to renal insufficiency (RI; n=6); (2) neurotoxicity (n=1) and pancytopenia (n=1); (3) vascular graft disease (VGD) treatment (n=5); (4) immunosuppression optimization due to lung cancer (n=2); (5) CI use was delayed due to postsurgery RI (n=2). The mean follow-up was 190+/-165 days. Mean SRL doses (mg)/concentrations (ng/mL) at 7 (n=17), 30 (n=14), and 180 (n=8) days were: 1.2+/-0.6/5.9+/-6; 1.6+/-0.8/4.8+/-3.1; and 1.7+/-1.0/5.2+/-3.7. Among group 1, CI patients were discontinued without favorable functional impact. Neurotoxicity and pancytopenia improved, but there were no major clinical events in the VGD group. One "bridge" to CI was successfully performed (postsurgery RI). Total leukocyte count fell while hemoglobin, platelet, and cholesterol profiles were not affected. Ten of 15 patients (67%) were discontinued from CI without rejection and with a dose reduction of mycophenolate mofetil. There were 8 episodes (47%) of SRL-related toxicity, leading to 4 discontinuations (23%); 8 patients (47%) have died during follow-up. This retrospective analysis of outcomes in the context of severe complicated patients suggests that more premature introduction SRL is preferable, particularly in a large patient cohort.

[Improvement of endothelial function in patients with hypercholesterolemia and normal coronary arteries with lipid-lowering therapy]. / Mejoría de la función endotelial al reducir las concentraciones lipídicas en pacientes con hipercolesterolemia y arterias coronarias normales.

INTRODUCTION AND AIMS: In patients with coronary risk factors the presence of endothelial dysfunction in epicardial arteries has been documented. The purpose of this study was to determine whether endothelial dysfunction, documented hypercholesterolemic patients and angiographically normal coronary arteries, improves by reduction and normalization of lipid levels. PATIENTS AND METHOD: In 10 patients with hypercholesterolemia and normal coronary angiography, the endothelium-dependent coronary vasomotion was studied by intracoronary infusion of acetylcholine into the left anterior descending coronary artery. Vasomotion changes in response to acetylcholine were analyzed by quantitative angiography. Five patients without coronary risk factors and normal coronary arteries formed the control group. Patients with hypercholesterolemia were treated with lipid-lowering therapy (diet and lovastatin) and endothelial function was reevaluated after 24 +/- 4 months. RESULTS: In the initial study, hypercholesterolemic patients compared with the control group showed a vasoconstrictor response to serial doses of acetylcholine(10(-6) M, 10(-5) M, 10(-4)M) indicative of endothelial dysfunction (study group: -0.3 +/- 10%, -6 +/- 4%, -18 +/- 10% vs control group: -0.6 +/- 6%, -2 +/- 6%, 3+/-6%; p < 0.01 to 10(-4) M acetylcholine dose. During follow-up hypercholesterolemic patients who a significant reduction in total cholesterol levels and LDL. Compared to first study, at follow-up, there was an improvement in the response to acetylcholine (-0.4 +/- 4%, -3 +/- 6%, -3 +/- 10%; p<0.001 vs basal values at 10(-4) M acetylcholine concentration). Reduction in total cholesterol during follow-up was related to the improvement in the vasoconstrictor response to acetylcholine (r=0.53; p< 0.05). CONCLUSION: In patients with hypercholesterolemia and angiographycally normal coronary arteries with documented endothelial dysfunction, the reduction and normalization of lipid levels during follow-up may improve endothelium-dependent coronary vasomotion.

Complete heart block in an adult with systemic lupus erythematosus and recent onset of hydroxychloroquine therapy.

Complete heart block (CHB) is a rare complication of systemic lupus erythematosus (SLE), mainly seen during an acute flare-up of the disease or after high-dose long-term treatment with antimalarial drugs, although anti-Ro and anti-RNP antibodies have also been implied by some authors. A 40-y-old woman developed CHB in the context of an acute flare-up of SLE, first diagnosed three years ago, having recently commenced hydroxychloroquine (HCQ) treatment. Anti-Ro and anti-RNP antibodies were also positive. No features of myocarditis were found. A temporary pacemaker was required and complete resolution was achieved on steroid therapy with withdrawal of antimalarial therapy. The characteristics of previous cases are well publicised and discussion focuses on the possible aetiology and pathogenesis of the present case.

Unidades de Hemodinámica y Cardiología Intervencionista / Hemodynamic and Interventionist Cardiac Units

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[Spontaneous multivessel coronary dissection as a cause of acute myocardial infarct--case report]]. / Dissecção coronária multivasos espontânea como causa de enfarte agudo do miocárdio--a propósito de um caso.

The authors describe a case reported in a young female with antecedents of aortic pathology and renovascular hypertension submitted to renal artery surgery admitted to emergency with an extensive acute myocardial infarction, treated with thrombolysis. After coronariography we identify, as etiological factor, a spontaneous coronary dissection involving the descending anterior coronary artery and circumflex coronary artery with no affect on the left main coronary artery. About this case, the authors make a brief review of the literature emphasizing the therapeutic options.

Stenting the stent: initial results and long-term clinical and angiographic outcome of coronary stenting for patients with in-stent restenosis.

Stent restenosis constitutes a therapeutic challenge affecting an increasing number of patients. Conventional angioplasty and debulking techniques are currently used in these patients. However, the potential role of a second stent implantation in this setting (stenting the stent) remains unknown. Therefore, 65 consecutive patients (12 women, aged 62 +/- 11 years) undergoing stent implantation (42 elective and 23 unplanned) for the treatment of in-stent restenosis (diffuse [> 10 mm] in 39 [60%]) were studied. Angiographic success was obtained in all patients. Three patients developed hospital complications: 1 died from refractory heart failure and 2 suffered non-Q-wave myocardial infarctions. During follow-up (mean 17 +/- 11 months) 1 patient died (noncardiac cause) and only 9 (14%) required target vessel revascularization. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) at 1 year was 84%. Using Cox analysis, patients with unstable symptoms, a short time to stent restenosis, nonelective stenting, and B2-C lesions tended to have poorer prognosis. After adjustment, nonelective stenting was associated (adjusted RR 2.9, 95% confidence interval [CI] 0.82 to 10.3, p = 0.09) with an adverse clinical outcome. On quantitative angiography (core lab) restenosis was found in 13 of 43 patients (30%) (75% of those eligible). Logistic regression analysis identify restenosis length (adjusted RR 1.43, 95% CI 1.04 to 2.14, p = 0.04), and time to restenosis (adjusted RR 0.67, 95% CI 0.47 to 0.94, p = 0.01) as the only independent predictors of recurrent restenosis. Thus, repeat coronary stenting is a safe and efficacious strategy for the treatment of patients with in-stent restenosis. Both elective and nonelective stenting provide excellent initial results. The long-term clinical and angiographic outcome of these patients is also favorable.

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation.

BACKGROUND: Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS: The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS: At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS: Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.

[The practical clinical guidelines of the Sociedad Española de Cardiología on interventional cardiology: coronary angioplasty and other technics]. / Guías de práctica clínica de la Sociedad Española de Cardiología en cardiología intervencionista: angioplastia coronaria y otras técnicas.

Interventional cardiology has had an extraordinary expansion in last years. This clinical guideline is a review of the scientific evidence of the techniques in relation to clinical and anatomic findings. The review includes: 1. Coronary arteriography. 2. Coronary balloon angioplasty. 3. Coronary stents. 4. Other techniques: directional atherectomy, rotational atherectomy, transluminal extraction atherectomy, cutting balloon, laser angioplasty and transmyocardial laser and endovascular radiotherapy. 5. Platelet glycoprotein IIb/IIIa inhibitors. 6. New diagnostic techniques: intravascular ultrasound, coronary angioscopy, Doppler and pressure wire. For the recommendations we have used the classification system: class I, IIa, IIb, III like in the guidelines of the American College of Cardiology and the American Heart Association.

[Right ventricular outflow obstruction due to a giant pseudoaneurysm of the anterior descending coronary artery in a patient with Behçet's disease]. / Obstrucción del tracto de salida del ventrículo derecho por un seudoaneurisma gigante de la arteria coronaria descendente anterior en un paciente con enfermedad de Behçet.

Giant pseudoaneurysms of coronary arteries in patients with Behçet's disease is a uncommon finding. It has been described exceptionally in the literature. We present a case of giant pseudoaneurysm of the left anterior descending coronary artery with obstruction of the right ventricular outflow in a patient with Behçet's disease. He improved after surgical resection and steroid treatment.

[Severe digoxin poisoning. The successful use of the classic treatment]. / Intoxicación grave por digoxina. Utilización exitosa del tratamiento clásico.

In our environment, the use of Fab antibodies for digoxin intoxication is often difficult due to the low availability of this drug in most centers. We present a case of massive digoxin intoxication that was successfully managed with the classic treatment. Later, we discuss the need to individualize the management of this kind of intoxications in order to reduce, when possible, sanitary costs.

Partial improvement in pulmonary function after successful percutaneous balloon mitral valvotomy.

STUDY OBJECTIVES: This study was performed to assess the changes in pulmonary function after a successful percutaneous balloon mitral valvotomy (PBMV) in 23 consecutive patients with symptomatic mitral stenosis. METHODS AND RESULTS: Lung function preprocedure and postprocedure were evaluated by spirometric flow, static pulmonary volumes, and diffusion capacity of the lung for carbon monoxide (DLCO). At baseline, a reduction in small airways flow (maximal expiratory flow at 50% of vital capacity, 70 +/- 29% of predicted value; maximal expiratory flow at 25% of vital capacity, 55 +/- 26% of predicted value) and an increase in DLCO (118 +/- 29%) and Krough Index (KCO; 123 +/- 29% of predicted value) were observed. PBMV caused an improvement in hemodynamic parameters with an increase in mitral valve area (from 1.0 +/- 0.3 to 1.9 +/- 0.5 cm(2); p < 0.001) and a decrease in left atrial pressure (from 17 +/- 3 to 12 +/- 5 mm Hg; p < 0.001). These changes were associated with a significant increase in FVC (from 2.8 +/- 0.84 to 2.9 +/- 0.80 L; p < 0.05) and in FEV(1) (from 2.2 +/- 0.72 to 2.3 +/- 0.68 L; p < 0.05). A decrease in DLCO was observed after PBMV (from 26.7 +/- 7 to 22.5 +/- 5.4 mL/min/mm Hg; p < 0.001; and KCO, from 6.2 +/- 1.4 to 5.2 +/- 1.2 mL/min/mm Hg/L; p < 0.001). No significant changes in small airways flow were detected, suggesting only a partial improvement in pulmonary congestion. CONCLUSION: We conclude that the initial impairment of lung function in patients with symptomatic mitral stenosis is only partially ameliorated by PBMV.

Influence of a nonionic, iso-osmolar contrast medium (iodixanol) versus an ionic, low-osmolar contrast medium (ioxaglate) on major adverse cardiac events in patients undergoing percutaneous transluminal coronary angioplasty: A multicenter, randomized, double-blind study. Visipaque in Percutaneous Transluminal Coronary Angioplasty [VIP] Trial Investigators.

BACKGROUND: The potential merits and disadvantages of the use of ionic or nonionic contrast media in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) have been the subjects of controversy. The present study was designed to evaluate the possible influence of both types of contrast media on major adverse cardiac events (MACE) in patients undergoing PTCA. METHODS AND RESULTS: In a randomized, parallel-group, double-blind study, 1411 patients received either iodixanol (a nonionic, iso-osmolar contrast medium) or ioxaglate (an ionic, low-osmolar contrast medium) during PTCA. A standardized anticoagulation regimen was followed. Patients were monitored in the hospital for 2 days and followed-up at 1 month. The primary end point, a composite of MACE (death, stroke, myocardial infarction, coronary artery bypass grafting, and re-PTCA) after 2 days, occurred in 4.3% of the total population, with no statistically significant difference between groups (iodixanol, 4.7%; ioxaglate, 3.9%; P=0.45). Further, between 2-day and 1-month follow-ups, no significant difference (P=0.27) existed between the groups in the rates of MACE. Hypersensitivity reactions (P=0.007) and adverse drug reactions (P=0.002) were significantly less frequent in the iodixanol group. The only significant predicting factors for the occurrence of MACE were dissection/abrupt closure and country. CONCLUSIONS: No significant differences were observed between the iodixanol and ioxaglate groups with regard to MACE, although hypersensitivity and adverse drug reactions were significantly less frequent in patients who received iodixanol.