Liquid biopsy-based protein biomarkers for risk prediction, early diagnosis, and prognostication of cholangiocarcinoma.

BACKGROUND & AIMS: Cholangiocarcinoma (CCA), heterogeneous biliary tumours with dismal prognosis, lacks accurate early diagnostic methods especially important for individuals at high-risk (i.e. those with primary sclerosing cholangitis [PSC]). Here, we searched for protein biomarkers in serum extracellular vesicles (EVs). METHODS: EVs from patients with isolated PSC (n = 45), concomitant PSC-CCA (n = 44), PSC who developed CCA during follow-up (PSC to CCA; n = 25), CCAs from non-PSC aetiology (n = 56), and hepatocellular carcinoma (n = 34) and healthy individuals (n = 56) were characterised by mass spectrometry. Diagnostic biomarkers for PSC-CCA, non-PSC CCA, or CCAs regardless of aetiology (Pan-CCAs) were defined and validated by ELISA. Their expression was evaluated in CCA tumours at a single-cell level. Prognostic EV biomarkers for CCA were investigated. RESULTS: High-throughput proteomics of EVs identified diagnostic biomarkers for PSC-CCA, non-PSC CCA, or Pan-CCA, and for the differential diagnosis of intrahepatic CCA and hepatocellular carcinoma, which were cross-validated by ELISA using total serum. Machine learning-based algorithms disclosed CRP/FIBRINOGEN/FRIL for the diagnosis of PSC-CCA (local disease [LD]) vs. isolated PSC (AUC = 0.947; odds ratio [OR] =36.9) and, combined with carbohydrate antigen 19-9, overpowers carbohydrate antigen 19-9 alone. CRP/PIGR/VWF allowed the diagnosis of LD non-PSC CCAs vs. healthy individuals (AUC = 0.992; OR = 387.5). It is noteworthy that CRP/FRIL accurately diagnosed LD Pan-CCA (AUC = 0.941; OR = 89.4). Levels of CRP/FIBRINOGEN/FRIL/PIGR showed predictive capacity for CCA development in PSC before clinical evidence of malignancy. Multi-organ transcriptomic analysis revealed that serum EV biomarkers were mostly expressed in hepatobiliary tissues, and single-cell RNA sequencing and immunofluorescence analysis of CCA tumours showed their presence mainly in malignant cholangiocytes. Multivariable analysis unveiled EV prognostic biomarkers, with COMP/GNAI2/CFAI and ACTN1/MYCT1/PF4V associated negatively and positively with patients' survival, respectively. CONCLUSIONS: Serum EVs contain protein biomarkers for the prediction, early diagnosis, and prognostication of CCA that are detectable using total serum, representing a tumour cell-derived liquid biopsy tool for personalised medicine. IMPACT AND IMPLICATIONS: The accuracy of current imaging tests and circulating tumour biomarkers for cholangiocarcinoma (CCA) diagnosis is far from satisfactory. Most CCAs are considered sporadic, although up to 20% of patients with primary sclerosing cholangitis (PSC) develop CCA during their lifetime, constituting a major cause of PSC-related death. This international study has proposed protein-based and aetiology-related logistic models with predictive, diagnostic, or prognostic capacities by combining two to four circulating protein biomarkers, moving a step forward into personalised medicine. These novel liquid biopsy tools may allow the (i) easy and non-invasive diagnosis of sporadic CCAs, (ii) identification of patients with PSC with higher risk for CCA development, (iii) establishment of cost-effective surveillance programmes for the early detection of CCA in high-risk populations (e.g. PSC), and (iv) prognostic stratification of patients with CCA, which, altogether, may increase the number of cases eligible for potentially curative options or to receive more successful treatments, decreasing CCA-related mortality.

Evaluation and Management of Liver Transplant Candidates With Prior Nonhepatic Cancer: Guidelines From the ILTS/SETH Consensus Conference.

Liver transplant in patients with prior nonhepatic cancer is a matter of concern, needing further research, development, and consensus guidelines. This International Liver Transplantation Society/Sociedad Española De Trasplante Hepático consensus conference document focuses on the role of liver transplantation in patients with a prior history of nonhepatic cancer. This document addresses (1) the evaluation of transplant candidates with prior cancers based on the assessment of prognosis, the natural history of individual cancers, and the emerging role for circulating DNA and minimal residual disease in these patients; (2) the impact of prior treatments, including immunotherapy for prior malignancies; and (3) the surveillance of posttransplant cancer recurrence. The consensus statement is based on previously published guidelines, as well as a review of the current, relevant, published literature.

Early tacrolimus exposure does not impact long-term outcomes after liver transplantation.

BACKGROUND: Tacrolimus trough levels (TTL) during the first weeks after liver transplantation (LT) have been related with long-term renal function and hepatocellular carcinoma recurrence. Nevertheless, the significance of trough levels of tacrolimus during the early post-transplant period for the long-term outcome is under debate. AIM: To evaluate the effect of TTL during the first month on the long-term outcomes after LT. METHODS: One hundred fifty-five LT recipients treated de novo with once-daily tacrolimus were retrospectively studied. Patients with repeated LT or combined transplantation were excluded as well as those who presented renal dysfunction prior to transplantation and/or those who needed induction therapy. Patients were classified into 2 groups according to their mean TTL within the first month after transplantation: ≤ 10 (n = 98) and > 10 ng/mL (n = 57). Multivariate analyses were performed to assess risk factors for patient mortality. RESULTS: Mean levels within the first month post-transplant were 7.4 ± 1.7 and 12.6 ± 2.2 ng/mL in the ≤ 10 and > 10 groups, respectively. Donor age was higher in the high TTL group 62.9 ± 16.8 years vs 45.7 ± 17.5 years (P = 0.002) whilst mycophenolate-mofetil was more frequently used in the low TTL group 32.7% vs 15.8% (P = 0.02). Recipient features were generally similar across groups. After a median follow-up of 52.8 mo (range 2.8-81.1), no significant differences were observed in: Mean estimated glomerular filtration rate (P = 0.69), hepatocellular carcinoma recurrence (P = 0.44), de novo tumors (P = 0.77), new-onset diabetes (P = 0.13), or biopsy-proven acute rejection rate (12.2% and 8.8%, respectively; P = 0.50). Eighteen patients died during the follow-up and were evenly distributed across groups (P = 0.83). Five-year patient survival was 90.5% and 84.9%, respectively (P = 0.44), while 5-year graft survival was 88.2% and 80.8%, respectively (P = 0.42). Early TTL was not an independent factor for patient mortality in multivariate analyses. CONCLUSION: Differences in tacrolimus levels restricted to the first month after transplant did not result in significant differences in long-term outcomes of LT recipients.

Diagnosis and treatment of hepatocellular carcinoma. Update of the consensus document of the AEEH, AEC, SEOM, SERAM, SERVEI, and SETH. / Diagnóstico y tratamiento del carcinoma hepatocelular. Actualización del documento de consenso de la AEEH, AEC, SEOM, SERAM, SERVEI y SETH.

Hepatocellular carcinoma (HCC) is the most common primary liver neoplasm and one of the most common causes of death in patients with cirrhosis of the liver. In parallel, with recognition of the clinical relevance of this cancer, major new developments have recently appeared in its diagnosis, prognostic assessment and in particular, in its treatment. Therefore, the Spanish Association for the Study of the Liver (AEEH) has driven the need to update the clinical practice guidelines, once again inviting all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document: Spanish Society for Liver Transplantation (SETH), Spanish Society of Diagnostic Radiology (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Association of Surgeons (AEC) and Spanish Society of Medical Oncology (SEOM). The clinical practice guidelines published in 2016 and accepted as National Health System Clinical Practice Guidelines were taken as the reference documents, incorporating the most important recent advances. The scientific evidence and the strength of the recommendation is based on the GRADE system.

A case of COVID-19 immediately after liver transplantation: Not only bad news.

COVID-19, the illness caused by the SARS-CoV-2 virus originated in December 2019 in Wuhan, China and has caused more 3,3 million cases and more than 230,000 deaths throughout the world, with 25,000 of them only in Spain, where the first case was diagnosed on January 31st, 2020. As COVID-19 is a "new" disease, we still do not have data on prognosis or treatment in transplant patients or on how to manage immunosuppression in this complex scenario. We present a case of COVID-19 diagnosed during the early postoperative period in a recipient whose liver transplantation was performed on late March during the lockdown in Spain, with donor and recipient previously negative rRT-PCR to SARS-CoV-2. In the first post-operative week the patient suffered COVID-19 pneumonia that was treated with immunosuppression minimization, oral Hydroxycloroquine and Azithromycin with favorable outcome. The patient was discharged on POD 21 without complications. To date, few early post-liver transplantation SARS-CoV-2 infected recipients have been published, but only one was an early postoperative infection. In our case the outcome was favorable, even though it was an early post -liver transplantation COVID-19 in a frail patient.

Favorable longterm outcomes of liver transplant recipients treated de novo with once-daily tacrolimus: Results of a single-center cohort.

The once-daily prolonged-release formulation of tacrolimus has been recently related with significant graft and patient mid-term survival advantages; however, practical information on the de novo administration after liver transplantation and longterm outcomes is currently lacking. This study is a 5-year retrospective analysis of a single-center cohort of liver transplant recipients treated de novo with once-daily tacrolimus (April 2008/August 2011). The study cohort consisted of 160 patients, including 23 with pretransplant renal dysfunction, with a median follow-up of 57.6 months (interquartile range, 46.6-69.0). Tacrolimus target trough levels were 5-10 ng/mL during the first 3 months after transplant, reducing progressively to <7 ng/mL after the first posttransplant year. Once-daily tacrolimus was withdrawn in 35 (21.8%) patients during follow-up, mostly due to renal dysfunction and/or metabolic syndrome. The biopsy-proven acute rejection rate was 12.5% with no cases of steroid-resistant rejection. The cumulative incidence of de novo diabetes, hypertension, and dyslipidemia were 16.9%, 31.2%, and 6.5%, respectively. Hepatocellular carcinoma recurrence rate was 2.8%. Renal function remained stable after the sixth month after transplant with a mean estimated glomerular filtration rate of 77.7 ± 19.6 mL/minute/1.73 m(2) at 5 years. None of our patients developed chronic kidney disease stage 4 or 5. Patient survival at 1, 3, and 5 years was 96.3%, 91.9%, and 88.3%, respectively. Overall survival of patients with Model for End-Stage Liver Disease (MELD) score > 25 points was not significantly different. In conclusion, our study suggests that immunosuppression based on de novo once-daily tacrolimus is feasible in routine clinical practice, showing favorable outcomes and outstanding longterm survival even in patients with high MELD scores. Liver Transplantation 22 1391-1400 2016 AASLD.

Renal function improvement in liver transplant recipients after early everolimus conversion: A clinical practice cohort study in Spain.

A national, multicenter, retrospective study was conducted to assess the results obtained for liver transplant recipients with conversion to everolimus in daily practice. The study included 477 recipients (481 transplantations). Indications for conversion to everolimus were renal dysfunction (32.6% of cases), hepatocellular carcinoma (HCC; 30.2%; prophylactic treatment for 68.9%), and de novo malignancy (29.7%). The median time from transplantation to conversion to everolimus was 68.7 months for de novo malignancy, 23.8 months for renal dysfunction, and 7.1 months for HCC and other indications. During the first year of treatment, mean everolimus trough levels were 5.4 (standard deviation [SD], 2.7) ng/mL and doses remained stable (1.5 mg/day) from the first month after conversion. An everolimus monotherapy regimen was followed by 28.5% of patients at 12 months. Patients with renal dysfunction showed a glomerular filtration rate (4-variable Modification of Diet in Renal Disease) increase of 10.9 mL (baseline mean, 45.8 [SD, 25.3] versus 57.6 [SD, 27.6] mL/minute/1.73 m(2) ) at 3 months after everolimus initiation (P < 0.001), and 6.8 mL at 12 months. Improvement in renal function was higher in patients with early conversion (<1 year). Adverse events were the primary reason for discontinuation in 11.2% of cases. The probability of survival at 3 years after conversion to everolimus was 83.0%, 71.1%, and 59.5% for the renal dysfunction, de novo malignancy, and HCC groups, respectively. Everolimus is a viable option for the treatment of renal dysfunction, and earlier conversion is associated with better recovery of renal function. Prospective studies are needed to confirm advantages in patients with malignancy.

[Therapeutic decisions in the treatment of hepatocellular carcinoma and patterns of sorafenib use. Results of the international observational GIDEON trial in Spain]. / Decisiones terapéuticas en el tratamiento del carcinoma hepatocelular y patrones de uso de sorafenib. Resultados del estudio internacional observacional GIDEON en España.

INTRODUCTION: GIDEON is a non-interventional, prospective, international study that evaluated the safety of sorafenib in patients with unresectable hepatocellular carcinoma (HCC) in daily clinical practice, including Child-Pugh B patients. OBJECTIVES: To analyze data collected in Spain on the safety and efficacy of sorafenib and treatment patterns. METHODS: Data were collected during follow-up on demographic and disease characteristics, the initial dose used, treatment-emergent adverse events (AEs) and dose modifications. Overall survival was evaluated, as well as time to disease progression. Efficacy and safety were analyzed according to the Child-Pugh classification and the initial dose. RESULTS: We included 143 patients from 19 Spanish hospitals. A total of 24.5% of the patients were Child-Pugh B. An initial dose of 400 mg/12 h was used in 90.9% of patients. In Child-Pugh A patients, dose modifications occurred more frequently and the treatment duration was longer. The incidence of AEs and drug-related AEs were similar in Child-Pugh A and B patients, although serious AEs were more frequent in Child-Pugh B patients. The most common AEs were diarrhea, fatigue and hand-foot skin reactions. The median overall survival was 384 days and was higher in Child-Pugh A patients (593 vs. 211 days in Child-Pugh B). The median time to disease progression was 177 days, similar in both subgroups. CONCLUSION: The safety profile of sorafenib in Spanish patients with unresectable HCC is independent of liver function. Child-Pugh status does not seem to influence the approach to sorafenib dosage or time to progression but does seem to be a strong prognostic factor for survival.

Efficacy and safety of sorafenib in combination with mammalian target of rapamycin inhibitors for recurrent hepatocellular carcinoma after liver transplantation.

There is currently no consensus on the most suitable treatment for the recurrence of hepatocellular carcinoma (HCC) after liver transplantation. This open, multicenter, retrospective, uncontrolled cohort study was designed to evaluate the safety and preliminary efficacy of the combined use of a mammalian target of rapamycin (mTOR) inhibitor and sorafenib in this setting. In 31 patients who suffered from HCC recurrence after liver transplantation, the immunosuppressive therapy was changed to mTOR inhibitors, and systemic treatment with sorafenib was initiated. This combination was maintained until symptomatic tumor progression, death, hepatic decompensation, or unacceptable toxicity occurred. Primary treatment efficacy was determined by overall survival and progression-free survival, and secondary efficacy was determined by the overall response rate. Toxicity parameters associated with the use of sorafenib and mTOR inhibitors were also analyzed. The overall response rate according to the Response Evaluation Criteria in Solid Tumors was 3.8% (1/26), and there was sustained stabilization of the disease in 13 additional cases (50.0%). The median overall survival was 19.3 months [95% confidence interval (CI) = 13.4-25.1 months], and the median time to progression was 6.77 months (95% CI = 2.3-11.1 months). Only 2 grade 3/4 cases of hyperglycemia and 1 case of grade 3/4 mucositis were reported, and they were possibly related to mTOR inhibitors. The most common severe adverse event probably related to sorafenib was diarrhea (12.9%). In conclusion, the coadministration of sorafenib and an mTOR inhibitor could be effective despite notable toxicity in patients with post-liver transplant HCC recurrence not suitable for radical therapy. The toxicity and efficacy need to be further evaluated in randomized controlled studies for this combination to be considered a valid option.

Evaluación de dss métodos de extracción de adn partir de biopsias fijadas en forMalina y embebidas en parafina en condiciones no pttimas / Evaluation of Two Methods DNA Extraction from Formalin-Fixed, Paraffin-Embedded Tissues on Non-Optimal Conditions

Los tejidos de archivo son material de incalculable valor para estudios retrospectivos que requieran la aplicación de análisis moleculares. Existen múltiples métodos de extracción de ADN a partir de este tipo de muestras. No obstante, la mayoría de métodos toman mucho tiempo y los reactivos empleados contribuyen a la fragmentación del ADN. Con el objetivo de optimizar dos métodos de extracción de ADN a partir de tejidos embebidos en parafina en condiciones no óptimas, se seleccionaron 47 bloques en parafina que contenían biopsias de pleura, pulmón y pericardio correspondientes a 24 pacientes (66,6% hombres) mayores de 18 años, con inflamación granulomatosa crónica, remitidos al Departamento de Patología, Hospital Universitario del Valle entre 2002 y 2007. Se realizaron 10 cortes a cada muestra y se sometieron a dos métodos de extracción de ADN: 1. convencional y 2. QIAamp-DNA mini kit®. La eficiencia del ADN fue valorada por espectrofotometría y amplificación del gen GAPDH. La concentración de ADN de las muestras extraídas por el método convencional fue de 65,52 ng/µL ±11,47 (promedio ± EE) y la relación 260/280 varió entre 0,52 y 2,30. De las muestras extraídas por el método comercial, la concentración media de ADN fue 60,89 ng/µL ± 6,02, con una absorbancia que osciló entre 0 y 2,64. El ADN obtenido fue sometido a PCR, de 47 muestras extraídas por ambos métodos, 25 y 23 respectivamente amplificaron exitosamente el gen GAPDH. Los métodos usados para la obtención de ADN presentaron un desempeño similar, revelando así su potencial utilidad en estudios retrospectivos a partir de biopsias embebidas en parafina en condiciones inadecuadas.

Paraffin wax embedded tissues are an invaluable material for retrospective studies requiring the application of molecular analysis. Multiple methods are available to extract DNA from these kind of samples. However, the most common methods are slow and the reagents often contribute to the fragmentation of genetic material. In order to optimize the procedure, two methods for DNA extraction from paraffin embedded tissue non-optimal conditions were used. 47 blocks containing paraffin-embedded biopsies of pleura, lung and pericardium from 24 patients (66.6% males) older than 18 years, with biopsy proven chronic granulomatous inflammation referred to the Department of Pathology at University hospital of Valle between 2002 and 2007 were selected. Each sample was subjected to 10 cuts and was to two methods of DNA extraction: 1. conventional and 2. QIAamp-DNA mini kit®. The efficiency of the extracted DNA, was assessed by spectrophotometry and PCR amplification of a fragment of the housekeeping gene GAPDH. The concentration of DNA samples extracted by the conventional method was of 65.52 ng/µL ± 11.47 (mean ± SE) and the 260/280 absorbance ratio ranged between 0.52 and 2.30 the average concentration of DNA of the samples extracted by the commercial method was 60.89 ng/µL ± 6.02 (mean ± SE), with an absorbance that fluctuated between 0 and 2.64. The DNA obtained was amplified by PCR, of 47 samples extracted by both methods, 25 and 23 respectively the GAPDH gene amplified successfully. The methods used to obtain DNA showed similar performance, highlighting the potential utility of both extraction methods for the retrospective studies from paraffin embedded tissues in unsuitable conditions.

Bacilos ácido accoholresistentes en biopsias emebidasen parafina en casos de iinflamacióngranulomatosa crónica. / Detection of Acid-Fast Bacilli in Formalin-Fixed,Paraffin-Embedded Tissues of Patientswith Chronic Granulomatous Inflammation.

La detección de bacilos ácido alcohol resistentes (BAAR) en frotis resulta un aporte significativo al diagnóstico y tratamiento de individuos con inflamación granulomatosa crónica (IGC). Con el objetivo de evaluar la presencia de BAAR en diferentes tejidos de pa-cientes con IGC demostrada y comparar la frecuencia de los extendidos positivos para BAAR con el grado de formación de granulomas y necrosis, se diseño un estudio retrospectivo, en el que se seleccionaron 57 bloques embebidos en parafina que contenían biopsias de pleura, pulmón, pericardio, ganglio linfático y lóbulo cerebral, correspon-dientes a 30 pacientes (63,3% hombres), mayores de 18 años, con IGC demostrada y remitidos al departamento de patología del Hospital Universitario del Valle entre el 2002-2008. A cada muestra se le realizaron tres cortes y se sometieron a tinciones de H/E, Zielh Neelsen y Auramina. La detección de BAAR en frotis fue similar para ambas tinciones especiales en pacientes con IGC necrotizante, reflejando una excelente concordancia en el diagnóstico (kappa=0,89, IC95%(0,68-1,0)). Sin embargo, la tinción con Auramina fue superior a la tinción Ziehl Neelsen para la detección de BAAR en pacientes con IGC no necrotizante (kappa=0,65, IC95%(0,23-1,0)). No se encontraron diferencias signi-ficativas entre la presencia de BAAR y el tipo de inflamacion, sexo y localización anatómica comprometida. En general, fue buena la concordancia entre los métodos histológicos empleados. Además, se hizo evidente la importancia de implementar el uso de técnicas moleculares mínimamente afectadas por el escaso número de bacilos presentes en las muestras, que finalmente ayudan en el reconocimiento del microorganismo.

Detection of acid fast bacilli (AFB) in smears is a significant aid in diagnosis and treatment of individuals with chronic granulomatous inflammation (CGI). This study was designed in order to detect the presence of AFB in several tissues of patients with histologically proven CGI and to compare the frequency of AFB positive smears with the degree of granuloma formation and necrosis. We selected 57 formalin-fixed, paraffin embedded blocks containing specimens of pleura, lung, pericardium, lymph nodes and cerebral lobe, from 30 patients (63.3% males) older than 18 years, with biopsy proven CGI referred to the Pathology department at University Hospital of Valle del Cauca (Colombia),between 2002 and 2008.Each sample was cut into 3 sections, and stained using the H/E, Ziehl-Neelsen and Auramine staining. AFB smear detection was similar in both special staining procedures in individuals with necrotizing CGI, reflecting an excellent diagnostic agreement (kappa=0.89, IC 95% (0.68-1.0)). However, Auramine was superior to Ziehl-Neelsen staining for AFB detection among subjects with nonnecrotizing CGI (kappa=0.65, IC95% (0.23-1.00)). Non-significant differences were found between the presence of AFB and the degree of granuloma necrosis, gender, and specific anatomic location. In general, there was a good agreement between both histological methods employed. Additionally it is clear that implementation of molecular tests that are minimally influenced by scant numbers of bacilli in samples is necessary for a definite diagnosis.

[Treatment approach of hepatocellular carcinoma in Spain. Analysis of 705 patients from 62 centers]. / Tratamiento del carcinoma hepatocelular en España. Análisis de 705 casos en 62 centros.

BACKGROUND AND OBJECTIVE: Hepatocellular carcinoma (HCC) is the leading cause of death in patients with cirrhosis and its current situation in Spain is not well known. Therefore, a national registry was created to assess the characteristics of patients with de novo HCC. PATIENTS AND METHOD: Between 1/10/2008 and 31/1/2009, 62 centers reported the baseline demographic, clinical and tumor characteristics, the first choice of treatment and eligibility for transplantation (OLT) of HCC diagnosed during this time. RESULTS: There were 705 new cases of HCC, 78% men, mean age 65 years, 89% cirrhosis (58% Child-Pugh class A, 42% HCV, 30% alcohol). Only 334 cases (47%) were diagnosed by screening. The size of the main nodule and BCLC stage were significantly lower in the screening group than in the rest (p<0.001). The applicability of radical therapies (resection and percutaneous ablation) was significantly higher (47.5% versus 24.6%, p<0.001) as well as the evaluation for OLT (31% versus 12%, p<0.001). The screening did not differ according to gender (p=0.204) or age (<50 years, <65, <75, >75 years) (p=0.171). Chemoembolization was the most common treatment: initial tumors (46.4%), tumors >5 cm (15.7%), multifocal HCC (37.9%) and as a bridge to OLT (33%). CONCLUSION: The majority of HCC patients are diagnosed in Spain out of early detection programs, and this limits the chance for early diagnosis and effective therapy.

Estudio por métodos no invasivos de las prótesis manufacturadas en el Instituto Nacional de Cardiología Ignacio Chávez / Non invasive study of manufactured prosthesis at the Instituto Nacional de Cardiologia Ignacio Chavez

Se estudian los registros fonocardiográficos, ecocardiográficos M, bidimensional y Doppler pulsado de 30 pacientes a los que se les implantó una prótesis de pericardio bovino manufacturada en el INCICH. Se describen solamente los 26 con prótesis en posición mitral, 22 mujeres y 4 hombres, de 19 a 60 años de edad. Después de la operación 22 están en clasificación I y 2 en clase II de la clasificación de la NYHA; los dos restantes (66%) fallecieron por causas no cardíacas. En el fonocardiograma: todos los pacientes presentaron chasquido de ciere protésico mitral (chCM); el intervalo Q-chCM fué de 0.09 + ou - 0.02 seg; el intervalo segundo ruido-chasquido de apertura protésico mitral (IIA-chAM) de 0.10 + ou - 0.01 seg. Se registró retumbo en 8 pacientes (30.7%). La pendiente O-F del apicograma fué de 82 mm/seg + ou - 4.0. Presentaban insuficiencia tricuspídea 10 pacientes. En la ecocardiografía: La velocidad D-E de apertura mitral fue de 318 mm/seg + ou - 99 y la de la pendiente E-F de 15.6 mm/seg + ou - 6.2. Todos excepto un paciente, presentaban movimiento paradójico del septum interventricular. La distancia entre postes fue de 14.1 mm + ou - 2; el diámetro interno de 17.8 mm + ou - 2.9 y el área valvular calculada de 2.5 cm2 + ou - 0.08. La velocidade de flujo/diámetro fue de 62.3 cm/seg/mm + ou - 26.8 y la velocidad de flujo/área de 52.5 cm/seg/cm2 + ou - 26.1. La información referida se considera importante por considerar que la fonocardiografía y la ecocardiografía son métodos sencillos y accesibles para el seguimiento del estado funcional de las prótesis, además de que permiten reconocer otras complicaciones. Es además el primer estudio de este tipo que analiza a las 30 primeiras prótesis implantadas entre febrero y julio de 1983, manufacturadas en este Instituto, con pericardio bovino