Venous thromboembolism in heart transplant recipients: incidence, recurrence and predisposing factors.

BACKGROUND: A high frequency of venous thromboembolism (VTE) has been observed after lung, kidney, and liver transplantation. However, data about the incidence of this complication among heart transplant (HT) recipients are lacking. METHODS: We analyzed the incidence, recurrence, and predisposing factors of VTE in a single-center cohort of 635 patients who underwent HT from April 1991 to April 2013. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were considered as VTE episodes. RESULTS: During a median post-transplant follow-up of 8.4 years, 62 VTE episodes occurred in 54 patients (8.5%). Incidence rates of VTE, DVT, and PE were, respectively, 12.7 (95% confidence interval [CI], 9.7-16.3), 8.4 (95% CI, 6.0-11.4), and 7.0 (95% CI 4.8-9.7) episodes per 1,000 patient-years. Incidence rates of VTE during the first post-transplant year and beyond were, respectively, 45.1 (95% CI, 28.9-67.1) and 8.7 (95% CI 6.2-11.2) episodes per 1,000 patient-years. The incidence rate of VTE recurrence after a first VTE episode was 30.5 (95% CI, 13.2-60.2) episodes per 1,000 patient-years. By means of multivariable Cox regression, chronic renal dysfunction, older age, obesity, and the use of mammalian target of rapamycin inhibitors were identified as independent risk factors for VTE among HT recipients. CONCLUSIONS: VTE is a frequent complication after HT, mainly during the first post-operative year. In view of a high recurrence rate, long-term anti-coagulation should be considered in HT recipients who experience a first VTE episode.

[Initial experience with excimer laser-assisted pacemaker and defibrillator lead extraction]. / Experiencia inicial con la extracción de electrodos de marcapasos y desfibrilador asistida con láser excimer.

Explantation of chronically implanted pacemaker or defibrillator leads can be technically demanding. We present the results of the first 44 leads extracted with excimer laser sheaths in 25 patients with a median lead implantation time of 7 years (range: 2 to 20 years). Indications for extraction were lead fracture in 17 patients, pocket infection in 4, septicemia in 2, and lead endocarditis in 2 cases. Complete extraction was achieved in 43 leads (97.7%), while the lead tip (< 4 cm) was abandoned in 1 case. There was no in-hospital mortality. The excimer laser-assisted system is a safe and efficient alternative for pacemaker and defibrillator lead extraction. This technology has resulted in excellent outcomes in our series, allowing us to treat remarkably difficult cases.

The effect of post-discharge educational intervention on patients in achieving objectives in modifiable risk factors six months after discharge following an episode of acute coronary syndrome, (CAM-2 Project): a randomized controlled trial.

OBJECTIVES: We investigated whether an intervention mainly consisting of a signed agreement between patient and physician on the objectives to be reached, improves reaching these secondary prevention objectives in modifiable cardiovascular risk factors six-months after discharge following an acute coronary syndrome. BACKGROUND: There is room to improve mid-term adherence to clinical guidelines' recommendations in coronary heart disease secondary prevention, specially non-pharmacological ones, often neglected. METHODS: In CAM-2, patients discharged after an acute coronary syndrome were randomly assigned to the intervention or the usual care group. The primary outcome was reaching therapeutic objectives in various secondary prevention variables: smoking, obesity, blood lipids, blood pressure control, exercise and taking of medication. RESULTS: 1757 patients were recruited in 64 hospitals and 1510 (762 in the intervention and 748 in the control group) attended the six-months follow-up visit. After adjustment for potentially important variables, there were, between the intervention and control group, differences in the mean reduction of body mass index (0.5 vs. 0.2; p < 0.001) and waist circumference (1.6 cm vs. 0.6 cm; p = 0.05), proportion of patients who exercise regularly and those with total cholesterol below 175 mg/dl (64.7% vs. 56.5%; p = 0.001). The reported intake of medications was high in both groups for all the drugs considered with no differences except for statins (98.1% vs. 95.9%; p = 0.029). CONCLUSIONS: At least in the short term, lifestyle changes among coronary heart disease patients are achievable by intensifying the responsibility of the patient himself by means of a simple and feasible intervention.

Effect of stent thrombosis on the risk-benefit balance of drug-eluting stents and bare metal stents.

INTRODUCTION AND OBJECTIVES: To determine the difference in the risk of stent thrombosis between drug-eluting stents (DES) and bare-metal stents (BMS) and to assess the clinical implications. METHODS: A retrospective analysis of two cohorts of patients treated at our center with either > or =1 paclitaxeleluting stents (PES) (n=430) or > or =1 BMSs (n=1230) during 2003-2004 was carried out using propensity score methods to compare the adjusted risks of stent thrombosis, instent restenosis, cardiovascular death, acute myocardial infarction (AMI), and target-lesion revascularization with the two stent types. RESULTS: After a median follow-up of 46 months, there was a higher risk of stent thrombosis in PESs (hazard ratio [HR]=3; 95% confidence interval [CI], 1.2-7.1] though the risk of in-stent restenosis was lower (HR=0.3; 95% CI, 0.2-0.7]. There was no difference in the risk of cardiovascular death, AMI or target-lesion revascularization. With PESs, the risks of target-lesion revascularization (HR=0.33; 95% CI, 0.2-0.7) and in-stent restenosis (HR=0.32; 95% CI, 0.2-0.7) were reduced during the first year of follow-up. After this time, the risks of target-lesion revascularization (HR=1.8; 95% CI, 1-3.2) and very late stent thrombosis (HR=12.8; 95% CI, 3-55.1) both increased. CONCLUSIONS: Our findings indicate that the balance of risks and benefits of PESs compared with BMSs is different in the early and late periods after stent implantation. The greatly increased risk of very late stent thrombosis in PESs could cancel out the clinical benefits associated with the reduction in in-stent restenosis observed in PESs relative to BMSs.

Effect of atrial fibrillation on outcome in patients with known or suspected coronary artery disease referred for exercise stress testing.

The association of atrial fibrillation (AF) with coronary artery disease (CAD) remains controversial. In addition, the relation of AF to myocardial ischemia and outcomes in patients with known or suspected CAD referred for exercise stress testing has been poorly explored. In this study, 17,100 patients aged > or = 50 years with known or suspected CAD who underwent exercise electrocardiography (n = 11,911) or exercise echocardiography (n = 5,189) were evaluated. End points were all-cause mortality, nonfatal myocardial infarction, and coronary revascularization. Overall, 619 patients presented with AF at the time of the tests. Patients with AF who had interpretable electrocardiograms had a lower likelihood of exercise-induced ischemic ST-segment abnormalities (adjusted odds ratio 0.51, 95% confidence interval 0.34 to 0.76, p = 0.001), and those with AF who underwent exercise echocardiography had a lower likelihood of new or worsening exercise-induced wall motion abnormalities (adjusted odds ratio 0.62, 95% confidence interval 0.44 to 0.87, p = 0.006). During a mean follow-up period of 6.5 + or - 3.9 years, 2,364 patients died, 1,311 had nonfatal myocardial infarctions, 1,615 underwent percutaneous coronary intervention, and 922 underwent coronary artery bypass surgery. The 10-year mortality rate was 43% in patients with AF compared to 19% in those without AF (p <0.001). In multivariate analysis, AF remained an independent predictor of all-cause mortality (adjusted hazard ratio 1.45, 95% confidence interval 1.20 to 1.76, p <0.001), but not of nonfatal myocardial infarction or coronary revascularization. In conclusion, despite being associated with an apparently lower likelihood of myocardial ischemia, AF was an independent predictor of all-cause mortality in patients with known or suspected CAD referred for exercise stress testing.

Natural history of a giant coronary aneurysm with spontaneous dissection.

Primary spontaneous coronary artery dissection may appear in young women during the peripartum period or as a result of atherosclerosis. We present a patient with familial hypercholesterolemia who developed a giant aneurysm of the right coronary artery in the setting of atherosclerotic spontaneous coronary dissection over an 8 year period. This report illustrates the association between spontaneous coronary artery dissection and subsequent coronary aneurysm formation.

Extrinsic compression of the left atrium by a mediastinal hematoma secondary to inadvertent carotid puncture.

We present the case of a 63-year-old man who underwent surgical closure of a paravalvular mitral leak. Immediately after surgery, transesophageal echocardiography revealed the appearance of a mediastinal hematoma encroaching on the left atrium and separating the esophageal probe from the posterior left atrial wall. The cause was an inadvertent puncture of the carotid artery, presumably during central venous line insertion prior to surgery.

Statin therapy and contrast-induced nephropathy after primary angioplasty.

A recent study suggested that statin therapy may prevent contrast-induced nephropathy (CIN) following primary angioplasty. Our aim was to assess the effect of statins in this setting in a larger population. We evaluated 589 consecutive patients with acute myocardial infarction who underwent primary angioplasty at our institution. Contrast-induced nephropathy was defined as an increase in serum creatinine by > or =0.5 mg/dL within 72 h following the procedure. Overall, 69 patients (11.9%) developed CIN. The incidence of CIN in the group on statins was 15.9%, as compared with 10.8% in the group not taking statins (p=0.2). Thus, we did not observe a protective effect of statin therapy on CIN development after primary angioplasty.

Humoral heart rejection (severe allograft dysfunction with no signs of cellular rejection or ischemia): incidence, management, and the value of C4d for diagnosis.

Severe allograft dysfunction after heart transplant (HT), without ischemia or evidence of cellular rejection upon endomyocardial biopsy (EMB), is a rare but potentially fatal condition that suggests humoral rejection (HR). Its incidence, and the methods of choice for its diagnosis and management, remain uncertain. We retrospectively studied 445 HT patients (April 1991-December 2003) to determine incidence of HR diagnosed by clinical and conventional histopathological criteria. We used immunofluorescence (IF) techniques to test archived frozen EMB issue for IgM, IgG, C1q, C3, fibrin and C4d. Twelve patients (2.7%) fulfilled the criteria for HR after a mean time post-HT of 21.3 +/- 24.7 months (range: 2-72 months). Patients were treated with high doses of steroids and plasmapheresis, with successful recovery in 11 cases. IF studies using classical markers were mainly negative for the six patients with enough EMB tissue for testing. All six patients showed positivity for C4d during the HR episode but not before or after. Humoral rejection was observed in less than 3% of HT patients. Plasmapheresis treatment was highly effective. Classical IF tests were not useful for diagnosis, but C4d appears to be useful both for confirmation of diagnosis and for monitoring response to treatment.

[Effect of a simple educational program for physicians on adherence to secondary prevention measures after discharge following acute coronary syndrome. The CAM Project]. / Efecto de un programa sencillo de educación de los profesionales en el cumplimiento de medidas de prevención secundaria en el momento del alta hospitalaria tras un síndrome coronario agudo. Proyecto CAM.

INTRODUCTION AND OBJECTIVES: Adherence to established guidelines for patients discharged from the hospital after acute coronary syndrome is known to be suboptimal. The aim of this study was to assess the efficacy of a program for physicians centered on the treatment of acute coronary syndrome. PATIENTS AND METHOD: 39 hospitals participated. INTERVENTION: a set of measures was developed by consensus for the creation and distribution of educational materials. OUTCOMES OF INTEREST: Proportion of patients in whom ejection fraction and residual ischemia were evaluated, treatment at discharge, and health and dietary recommendations to patients (smoking, diet, exercise, etc.) referred to all patients in whom these measures or treatments should have been used ("ideal patients"). Changes were assessed with four cross-sectional surveys. RESULTS: A total of 1157, 1162, 1149 and 1158 patients were included. There were no relevant differences between these groups in baseline characteristics. In general, there was improvement in all variables between the first and the last survey. The proportion of patients who were weighed and measured increased (from 33.5% to 53.4%; P<.0001), as did the proportion of those in whom cholesterol was measured early (42.6 to 53.7%; P=.006). The proportion in whom residual ischemia was not measured despite indications for this test decreased (18.2% to 10.8%; P=.013), and the proportion increased for appropriate treatment with statins on discharge (68.6% to 81.4%; P<.0001), advice to quit smoking (60.1% to 72.2%; P<.0001) and advice to exercise (58.3% to 67.4%; P=.003). CONCLUSIONS: The educational intervention seems to have had a positive effect on improving the appropriateness of procedures and treatments for patients discharged after acute coronary syndrome.

Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial.

BACKGROUND: In patients with ST-segment elevated myocardial infarction (STEMI), early post-thrombolysis routine angioplasty has been discouraged because of its association with high incidence of events. The GRACIA-1 trial was designed to reassess the benefits of an early post-thrombolysis interventional approach in the era of stents and new antiplatelet agents. METHODS: 500 patients with thrombolysed STEMI (with recombinant tissue plasminogen activator) were randomly assigned to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia-guided conservative approach. The primary endpoint was the combined rate of death, reinfarction, or revascularisation at 12 months. Analysis was by intention to treat. FINDINGS: Invasive treatment included stenting of the culprit artery in 80% (199 of 248) patients, bypass surgery in six (2%), non-culprit artery stenting in three, and no intervention in 40 (16%). Predischarge revascularisation was needed in 51 of 252 patients in the conservative group. By comparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44 [95% CI 0.28-0.70], p=0.0008), and they tended to have reduced rate of death or reinfarction (7% vs 12%, 0.59 [0.33-1.05], p=0.07). Index time in hospital was shorter in the invasive group, with no differences in major bleeding or vascular complications. At 30 days both groups had a similar incidence of cardiac events. In-hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative group than in those in the invasive group. INTERPRETATION: In patients with STEMI, early post-thrombolysis catheterisation and appropriate intervention is safe and might be preferable to a conservative strategy since it reduces the need for unplanned in-hospital revascularisation, and improves 1-year clinical outcome.

Left-right asymmetric ventricular expression of CARP in the piglet heart: regional response to experimental heart failure.

BACKGROUND AND AIM: Cardiac ankyrin repeat protein (CARP), whose expression is down-regulated in response to doxorubicin (Dox) in vitro, has been proposed to be a marker of experimentally-induced cardiac hypertrophy in rodent models. In piglets, the rapid hypertrophy rate of the left ventricle (LV) as compared to that of the right ventricle (RV) represents a natural model of asymmetric ventricular enlargement. We tested whether CARP expression correlates with postnatal ventricular hypertrophy and to what extent CARP can be sensitive to Dox treatment in vivo. METHODS: CARP mRNA and protein levels were quantified (by Northern blot hybridization, semi-quantitative RT-PCR and Western blot) in the piglet heart, both during early postnatal development and upon Dox-induced cardiomyopathy (Dox-CM). RESULTS: The study revealed: (1) significantly augmented CARP mRNA and protein levels in the LV compared to the RV resulting in left vs. right asymmetry in ventricular CARP expression throughout early postnatal development; (2) dose- and chamber-dependent CARP mRNA and protein enrichment in ventricular myocardium in response to Dox; and (3) abolishment of asymmetric patterns of ventricular CARP expression at heart failure resulting from Dox-CM. CONCLUSIONS: (1) CARP is differentially regulated in the LV and RV during both postnatal development and disease; and (2) monitoring of ventricular CARP expression patterns can be used for further analysis of transition from compensated to overt heart failure.

[Management by hypothermia of junctional ectopic tachycardia appearing after pediatric heart surgery]. / Tratamiento mediante hipotermia de la taquicardia ectópica de una unión tras cirugía cardíaca infantil.

Junctional ectopic tachycardia (JET) is a complication of the repair of congenital cardiac malformations that responds poorly to conventional treatment. We report our experience with the use of moderate hypothermia in its management. Twelve infants with postoperative JET treated with hypothermia were reviewed. The mean interval between the diagnosis of JET and initiation of hypothermia was 1.5 0.5 hours. In the first 24 hours of hypothermia, central temperature and heart rate decreased significantly. Arterial pressure and diuresis tended to increase and central venous pressure tended to decrease. No direct adverse events occurred. All the patients but one survived and are alive and free of neurological deficits after 15 12 months.

[Inflammation markers and risk stratification in patients with acute coronary syndromes: design of the SIESTA Study (Systemic Inflammation Evaluation in Patients with non-ST segment elevation Acute coronary syndromes)]. / Marcadores de inflamación y estratificación de riesgo en pacientes con síndorome coronario agudo: diseño del estudio SIESTA (Systemic Inflammation Evaluation in patients with non-ST segment elevaton Acute coronary syndromes).

BACKGROUND AND OBJECTIVE: Evidence is growing regarding the prognostic value of markers of inflammation in unstable angina/non-ST segment elevation myocardial infarction (UA/NSTEMI). However, the independent value of these variables has not been systematically investigated in prospective studies. The main objective of the SIESTA study is to assess the relative prognostic roles of C-reactive protein, fibrinogen, neopterin, interleukins 6, 8, 10 and 18, tumor necrosis factor, e-selectin, endothelin 1, tissue factor, VCAM-1, ICAM-1, pregnancy-associated plasma protein-A, B-type natriuretic peptide, leukocytes, troponin I or T and serum creatine kinase-MB (CKMB) in UA/NSTEMI patients. PATIENTS AND METHOD: SIESTA is a prospective, multicenter trial involving patients with chest pain suggestive of acute coronary syndrome (ACS) within 48 hours of enrolment and at least one of the following: abnormal troponin levels, electrocardiographic signs of ischaemia or previously documented vascular disease. Clinical outcome data and serial biochemical determinations will be assessed during hospital admission and at 30, 180 and 365 days of follow-up. The TIMI (Thrombolysis In Myocardial Infarction) and PEPA (Proyecto de Estudio del Pronóstico de la Angina) risk scores will be also validated. Study variables will include death due to any cause, cardiac death, non-fatal myocardial infarction, unstable angina requiring re-admission, emergency revascularization and a composite of death, myocardial infarction and need for emergency hospitalization or myocardial revascularization. Each of these conditions will be treated as secondary end-points when assessed individually. This study will provide valuable prospective information about the prognostic value of inflammatory markers in real life ACS patients of Mediterranean origin.

[Transradial approach to coronary angiography and angioplasty: initial experience and learning curve]. / Coronariografía y angioplastia coronaria por vía radial: experiencia incial curva de aprendizaje.

INTRODUCTION: The transradial approach has emerged as an attractive alternative to the femoral approach for coronary angiography and interventions. We describe our experience with the transradial approach and analyze the influence of the learning curve. PATIENTS AND METHODS: The transradial approach was attempted in patients with a good radial pulse and normal Allen test. When feasible and clinically indicated, we attempted ad hoc intervention. We divided the study population into two groups: Group A (the first 200 cases) and B (all other patients). We compared the radial group with a matched femoral control group. RESULTS: We attempted the transradial approach in 526 patients (77.6% male; age 63.5 +/- 11.51), and obtained a success rate of 93.7%. We found differences between group A and B in the success rate (91.0 vs 95.4%, p = 0,04), duration of procedure [23 (16-29) vs. 19 (15-24) minutes; p < 0.001], and fluoroscopy time [6.4 (4.2-10) vs. 5.0 (3.0-7.7) minutes; p < 0,001]. At 24 h of follow-up, we found small hematomas in 9.4%, bleeding in 4.9%, and radial artery obstruction in 2.8%, with no cases of arteriovenous fistula, pseudoaneurysm, or need for vascular surgery. We attempted intervention in 169 patients with 258 lesions, achieving angiographic success in 96.1%. We found no differences in the characteristics of the lesions and patients, or in the angiographic success rate of the radial and femoral PTCA groups. CONCLUSIONS: The transradial approach is a safe and effective alternative to femoral catheterization. There is a significant learning curve associated with the successful performance of transradial procedures.