Noninvasive Liver Assessment in Adult Patients With Fontan Circulation Using Acoustic Radiation Force Impulse Elastography and Hepatic Magnetic Resonance Imaging.

BACKGROUND: Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). METHODS: In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. RESULTS: Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. CONCLUSIONS: There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.

Idarucizumab in High-risk Thoracic Surgery.

Direct oral anticoagulants have suggested a favorable profile compared with vitamin K antagonists. However, the lack of treatment to reverse the effect of direct oral anticoagulants has limited its use in some patients who require rapid reversal of anticoagulation, as those included in the transplant waiting list. Idarucizumab is a recently approved drug to reverse the anticoagulant effect of dabigatran. However, the clinical experience when using this drug is scarce. Herein, we present a clinical case on anticoagulation reversal with idarucizumab to perform heart and lung transplantation in a patient with Eisenmenger syndrome.

High-Bandpass Filters in Electrocardiography: Source of Error in the Interpretation of the ST Segment.

Introduction. Artifactual variations in the ST segment may lead to confusion with acute coronary syndromes. Objective. To evaluate how the technical characteristics of the recording mode may distort the ST segment. Material and Method. We made a series of electrocardiograms using different filter configurations in 45 asymptomatic patients. A spectral analysis of the electrocardiograms was made by discrete Fourier transforms, and an accurate recomposition of the ECG signal was obtained from the addition of successive harmonics. Digital high-pass filters of 0.05 and 0.5 Hz were used, and the resulting shapes were compared with the originals. Results. In 42 patients (93%) clinically significant alterations in ST segment level were detected. These changes were only seen in "real time mode" with high-pass filter of 0.5 Hz. Conclusions. Interpretation of the ST segment in "real time mode" should only be carried out using high-pass filters of 0.05 Hz.

Effect of circulatory assistance on premature death and long-term prognosis.

BACKGROUND: Patients undergoing urgent heart transplantation (HT) have a poorer prognosis and more long-term complications. The objective of this study was to compare the preoperative course in patients undergoing urgent HT according to the need for preoperative intra-aortic balloon counterpulsation (IABP). MATERIALS AND METHODS: We studied 102 consecutive patients including 23 patients with IABP who underwent urgent HT between January 2000 and September 2006. We excluded patients who received combination transplants, those who underwent repeat HT, and pediatric patients who underwent HT. The statistical methods used were the t test for quantitative variables and the chi(2) test for qualitative variables. A logistic regression model was constructed to assess the possible relationship between IABP and other variables on premature death within 30 days after HT. RESULTS: Mean (SD) patient-age was 50 (10) years. No significant differences were observed in baseline characteristics between the IABP and the non-IAPB groups. The IABP patient group had higher rates of acute graft failure (45.5% vs 35.4%; P = .46) and premature death (18.8% vs 14.8%; P = .67) and shorter long-term survival (40.6 [34.9] vs 54.5 [43.7] mo; P = .30). Multivariate analysis demonstrated no association between the need for IABP and increased frequency of premature death. CONCLUSIONS: Use of IABP is not associated with premature or late death. We recommend use of IABP in patients with acute decompensated heart failure to stabilize them before HT.

Effect of hypertension, diabetes, and smoking on development of renal dysfunction after heart transplantation.

BACKGROUND: Renal dysfunction is a serious problem after heart transplantation (HT). The objective of this study was to determine the cardiovascular risk factors associated with medium- to long-term dysfunction after HT. MATERIALS AND METHODS: We studied 247 consecutive patients who underwent HT between January 2000 and September 2006 who survived for at least 6 months. We excluded patients receiving combination transplants, those undergoing repeat HT, and pediatric patients undergoing HT. Mean (SD) follow-up was 72 (42) months. We defined renal dysfunction as serum creatinine concentration greater than 1.4 mg/dL during follow-up. Patients were considered to be smokers if they had smoked during the six months before HT, to have hypertension if they required drugs for blood pressure control, and to have diabetes if they required insulin therapy. Statistical tests included the t test and the chi(2) tests. We performed Cox regression analysis using significant or nearly significant values in the univariate analysis. RESULTS: Mean (SD) age of the patients who underwent HT was 52 (10) years, and 217 (87.9%) were men. Renal dysfunction was detected during follow-up in 135 (54.5%) patients. The significant variables at univariate analysis were smoking (61.4% vs. 43.2%; P = .01) and previous renal dysfunction (94.1% vs 52.7%; P = .001). Nearly significant variables were the presence of hypertension before HT (63.8% vs 51.1%; P = .09) and after HT (58.2% vs 44.8%; P = .082). At multivariate analysis, pre-HT smoking and previous renal dysfunction were significant correlates (P = .04 and P = .01, respectively). CONCLUSIONS: Renal dysfunction is common after HT. In our analysis, the best predictors were pre-HT dysfunction and smoking. Less important factors were advanced age and post-HT hypertension.

[Utility of pravastin in cardiac transplant dyslipidemia]. / Utilidad de la pravastina en la dislipidemia del trasplante cardíaco.

Patients undergoing cardiac transplantation are at increased risk of dyslipidemia (60% to 80%). Lipid-lowering treatment in these patients should be aggressive given the known role of dyslipidemia in chronic transplant rejection. The objective of this study was to evaluate the efficacy and safety of pravastatina therapy and its effect upon cyclosporine levels in a population of dyslipidemic cardiac transplant patients.A total of 20 cardiac transplant patients were enrolled in this 39-week length prospective observational study. Patients had serum cholesterol levels exceeding 200 mg/dl, and received pravastatin therapy at the adequate dose to obtain an optimal lipid profile without significant adverse effects. Pravastatin, at a mean dose of 50 18 mg/day, produced a significant reduction in total cholesterol levels (from 291 32 to 203 25 mg/dl, p < 0.05), LDL cholesterol (from 187 34 to 102 15 mg/dl, p < 0.05) and an increase in HDL-cholesterol levels (from 48 16 to 55 14, p < 0.05). A slight asymptomatic increase in CPK levels was observed but no differences in cyclosporine levels. Pravastatin has shown to be an effective and safe therapy in dyslipidemic cardiac transplant patients.

[Emergency implantation of intracoronary stent after acute occlusion of the common trunk of the left coronary artery]. / Implantación emergente de stent intracoronario tras oclusión aguda del tronco común de la coronaria izquierda.

Nowadays, the implantation of coronary endoprosthesis within the left main coronary artery is not considered as an absolute contraindication. Here, we show a case of acute occlusion within the left main coronary artery. This was resolved by implanting a stent during a programmed cardiac catheterization. It should be stressed that this problem was occurred without manipulating the left coronary tree. In addition, the patient was in cardiac arrest when the stent was implanted. Cardiopulmonary resuscitation was applied because of this condition.