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1.
Heart Fail Rev ; 27(6): 2017-2031, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-35430696

RESUMEN

The fact that nearly 50% of patients with an aortic valve (AV) area < 1.0 cm2, consistent with severe aortic stenosis (AS), can have mean trans-AV pressure gradients < 40 mmHg, consistent with non-severe AS, indicates that "low-gradient" (LG) severe AS, which is often associated with poor prognosis, deserves particular consideration. Inadequate left ventricular (LV) adaptation to severe AV stenosis resulting from preexistent intrinsic myocardial damages and/or maladaptive LV responses to increased afterload are typical features of severe LG-AS. The diagnosis and management of patients with severe LG-AS are particularly challenging because the discrepancy between the AV area and the trans-AV pressure gradient raises doubts concerning the actual severity of AS and therefore also about the necessity of AV replacement (AVR). LG-AS diagnosis requires integrative multimodality evaluation of both the AV and the LV and therapeutic decision-making necessitates careful individual benefit-risk estimation. Although patients with severe LG-AS associated with low trans-AV flow (i.e., stroke volume ≤ 35 ml/m2) have worse outcomes after AVR than those with high-gradient severe AS, even those with reduced LV ejection fraction (LVEF) can have a significant survival benefit particularly by transcatheter AVR. Dobutamine stress echocardiography facilitates distinction between true-severe and pseudo-severe low-flow LG-AS with reduced LVEF. The review aimed to provide an updated theoretical and practical basis for those engaged in this demanding and still current topic due to the new aspects which have emerged in conjunction with both the evolving scientific knowledge about the various LV responses to the increased afterload and the increasing use of the less invasive transcatheter AVR.


Asunto(s)
Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Volumen Sistólico/fisiología , Resultado del Tratamiento , Función Ventricular Izquierda/fisiología
2.
Heart Fail Rev ; 26(2): 319-336, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-32889634

RESUMEN

Allograft rejection-related acute and chronic heart failure (HF) is a major cause of death in heart transplant recipients. Given the deleterious impact of late recognized acute rejection (AR) or non-recognized asymptomatic antibody-mediated rejection on short- and long-term allograft function improvement of AR surveillance and optimization of action strategies for confirmed AR can prevent AR-related allograft failure and delay the development of cardiac allograft vasculopathy, which is the major cause for HF after the first posttransplant year. Routine non-invasive monitoring of cardiac function can improve both detection and functional severity grading of AR. It can also be helpful in guiding the anti-AR therapy and timing of routine surveillance endomyocardial biopsies (EMBs). The combined use of EMBs with non-invasive technologies and methods, which allow detection of subclinical alterations in myocardial function (e.g., tissue Doppler imaging and speckle-tracking echocardiography), reveal alloimmune activation (e.g., screening of complement-activating donor-specific antibodies and circulating donor-derived cell-free DNA) and help in predicting the imminent risk of immune-mediated injury (e.g., gene expression profiling, screening of non-HLA antibodies, and circulating donor-derived cell-free DNA), can ensure the best possible surveillance and management of AR. This article gives an overview of the current knowledge about the reliability and clinical value of non-invasive cardiac allograft AR surveillance. Particular attention is focused on the potential usefulness of non-invasive tools and techniques for detection and functional grading of early and late ARs in asymptomatic patients. Overall, the review aimed to provide a theoretical and practical basis for those engaged in this particularly demanding up-to-date topic.


Asunto(s)
Insuficiencia Cardíaca , Trasplante de Corazón , Aloinjertos , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/prevención & control , Insuficiencia Cardíaca/prevención & control , Trasplante de Corazón/efectos adversos , Humanos , Reproducibilidad de los Resultados
3.
Am Heart J ; 206: 30-50, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30300847

RESUMEN

By reduction of ventricular wall-tension and improving the blood supply to vital organs, ventricular assist devices (VADs) can eliminate the major pathophysiological stimuli for cardiac remodeling and even induce reverse remodeling occasionally accompanied by clinically relevant reversal of cardiac structural and functional alterations allowing VAD explantation, even if the underlying cause for the heart failure (HF) was dilated cardiomyopathy. Accordingly, a tempting potential indication for VADs in the future might be their elective implantation as a therapeutic strategy to promote cardiac recovery in earlier stages of HF, when the reversibility of morphological and functional alterations is higher. However, the low probability of clinically relevant cardiac improvement after VAD implantation and the lack of criteria which can predict recovery already before VAD implantation do not allow so far VAD implantations primarily designed as a bridge to cardiac recovery. The few investigations regarding myocardial reverse remodeling at cellular and sub-cellular level in recovered patients who underwent VAD explantation, the differences in HF etiology and pre-implant duration of HF in recovered patients and also the differences in medical therapy used by different institutions during VAD support make it currently impossible to understand sufficiently all the biological processes and mechanisms involved in cardiac improvement which allows even VAD explantation in some patients. This article aims to provide an overview of the existing knowledge about VAD-promoted cardiac improvement focusing on the importance of bench-to-bedside research which is mandatory for attaining the future goal to use long-term VADs also as therapy-devices for reversal of chronic HF.


Asunto(s)
Insuficiencia Cardíaca/terapia , Ventrículos Cardíacos/fisiopatología , Corazón Auxiliar , Recuperación de la Función/fisiología , Insuficiencia Cardíaca/fisiopatología , Humanos
4.
Heart Fail Rev ; 23(2): 157-171, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29453695

RESUMEN

Severe right ventricular (RV) failure is more likely reversible than similar magnitudes of left ventricular (LV) failure and, because reversal of both adaptive remodeling and impaired contractility require most often only short periods of support, the use of temporary RV assist devices (t-RVADs) can be a life-saving therapy option for many patients. Although increased experience with t-RVADs and progresses made in the development of safer devices with lower risk for complications has improved both recovery rate of RV function and patient survival, the mortality of t-RVAD recipients can still be high but it depends mainly on the primary cause of RV failure (RVF), the severity of end-organ dysfunction, and the timing of RVAD implantation, and much less on adverse events and complications related to RVAD implantation, support, or removal. Reduced survival of RVAD recipients should therefore not discourage appropriate application of RVADs because their underuse further reduces the chances for RV recovery and patient survival. The article reviews and discusses the challenges related to the pre-implant and post-implant decision-making processes aiming to get best possible therapeutic results. Special attention is focused on pre-implant RV assessment and prediction of RV improvement during mechanical unloading, patient selection for t-RVAD therapy, assessment of unloading-promoted RV recovery, and prediction of its stability after RVAD removal. Particular consideration is also given to prediction of RVF after LVAD implantation which is usually hampered by the complex interactions between the different risk factors related indirectly or directly to the RV potential for reverse remodeling and functional recovery.


Asunto(s)
Insuficiencia Cardíaca/cirugía , Ventrículos Cardíacos/fisiopatología , Corazón Auxiliar , Implantación de Prótesis , Disfunción Ventricular Derecha/cirugía , Función Ventricular Derecha/fisiología , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/cirugía , Humanos , Periodo Posoperatorio , Periodo Preoperatorio , Disfunción Ventricular Derecha/fisiopatología
5.
BMC Cardiovasc Disord ; 18(1): 144, 2018 07 11.
Artículo en Inglés | MEDLINE | ID: mdl-29996761

RESUMEN

The potential life-threatening consequences of catecholamine use for emergency circulatory support in Takotsubo cardiomyopathy-related acute heart failure is a major challenge in cardiovascular emergences. In their recent work in BMC Cardiovascular Disorders Ansari U. et al. demonstrated the harmful effects of catecholamines on the outcome of patients with Takotsubo cardiomyopathy. Concerning this matter we emphasize the usefulness of speckle-tracking-derived echocardiography for early recognition of an acute phase of a Takotsubo syndrome in order to avoid the deleterious effects of a catecholamine therapy in patients with Takotsubo-associated acute heart failure.


Asunto(s)
Insuficiencia Cardíaca , Cardiomiopatía de Takotsubo , Catecolaminas , Ecocardiografía , Humanos
6.
Artículo en Inglés | MEDLINE | ID: mdl-29425525

RESUMEN

We report the techniques and long-term outcome of mitral valve (MV) repair to correct congenital mitral stenosis in children. Between 1986 and 2014, 137 children (mean age 4.1 ± 5.0, range 1 month-16.8 years) underwent repair of congenital mitral stenosis (CMS). In 48 patients, CMS is involved in Shone's anomaly. The typical congenital MS (type I) was seen in 56 patients. Hypoplastic MV (type II, n = 15) was associated with severe left ventricular outflow tract abnormalities and hypoplastic left ventricular cavity and muscle mass. Supravalvar ring (type III, n = 48) ranged from a thin membrane to a thick discrete fibrous ridge. Parachute MV (type IV, n = 10) have 2 leaflets and barely distinguishable commissures, but all chordae merged either into 1 major papillary muscle or asymmetric papillary muscles-1 dominant and the other minuscule. Hammock valve (type IV, n = 8) appeared dysplastic with shortened chordae directly inserted into the posterior left ventricular muscle mass. MV repair was performed using commissurotomy, chordal division, papillary muscle splitting and fenestration, and mitral ring resection, each applied according to the presenting morphology. During the 28-year follow-up period, 23 patients underwent repeat MV repair and 3 underwent MV replacement after failed attempts at repeat repair. At 1 and 15 years postoperatively, freedom from reoperation was 89.3 ± 5.1% and 52.8 ± 11.8%, and cumulative survival rates were 92.3 ± 4.3% and 70.3 ± 8.9, respectively. Mortality unrelated to repair accounted for 9 (20%) deaths. Long-term functional outcome of MV repair in children with CMS is satisfactory. Repeat repair or replacement may be deemed necessary during the course of follow-up.


Asunto(s)
Estenosis de la Válvula Mitral/congénito , Estenosis de la Válvula Mitral/cirugía , Procedimientos de Cirugía Plástica/métodos , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Estenosis de la Válvula Mitral/mortalidad , Músculos Papilares/cirugía , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
8.
Emerg Med J ; 34(12): 831-841, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-27852651

RESUMEN

The number of ventricular assist devices (VADs) being implanted for terminal heart failure is rising at an exponential rate. These implanted patients have a decreased mortality, but still have significant morbidities, as the prevalence of these patients increases in the community. When VAD patients are discharged to home, they will very likely require emergency medical services (EMSs) and emergency medical doctors (EDs) with their future care. The interface of these patients with the community would suggest an increasing prevalence of encounters requiring the need for acute medical care. This will place the initial responsibility of these patients in the hands of EMS first responders and emergency room providers. To date, there is very little literature published on out-of-hospital or ED care for VAD patients. Most EMS personnel and ED feel uncomfortable treating a patient with a VAD because they have not had sufficient exposure. The cardiovascular treatment of VAD patients in the field can pose different challenges typically encountered including difficulties measuring a pulse and sometimes undetectable BP. Despite these unique challenges, official guidelines or even standard operating procedures regarding the emergency treatment of VAD patients are still lacking. We present a basic overview of the most commonly used left VAD systems and propose guidelines that should be followed in the event of an emergency with a VAD patient out of hospital.


Asunto(s)
Servicios Médicos de Urgencia , Tratamiento de Urgencia , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Diseño de Equipo , Humanos , Guías de Práctica Clínica como Asunto
9.
Hum Mol Genet ; 23(12): 3115-28, 2014 Jun 15.
Artículo en Inglés | MEDLINE | ID: mdl-24459294

RESUMEN

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its genetic basis is demonstrated by an increased recurrence risk in siblings and familial cases. However, the majority of TOF are sporadic, isolated cases of undefined origin and it had been postulated that rare and private autosomal variations in concert define its genetic basis. To elucidate this hypothesis, we performed a multilevel study using targeted re-sequencing and whole-transcriptome profiling. We developed a novel concept based on a gene's mutation frequency to unravel the polygenic origin of TOF. We show that isolated TOF is caused by a combination of deleterious private and rare mutations in genes essential for apoptosis and cell growth, the assembly of the sarcomere as well as for the neural crest and secondary heart field, the cellular basis of the right ventricle and its outflow tract. Affected genes coincide in an interaction network with significant disturbances in expression shared by cases with a mutually affected TOF gene. The majority of genes show continuous expression during adulthood, which opens a new route to understand the diversity in the long-term clinical outcome of TOF cases. Our findings demonstrate that TOF has a polygenic origin and that understanding the genetic basis can lead to novel diagnostic and therapeutic routes. Moreover, the novel concept of the gene mutation frequency is a versatile measure and can be applied to other open genetic disorders.


Asunto(s)
Predisposición Genética a la Enfermedad , Variación Genética , Estudio de Asociación del Genoma Completo/métodos , Miocardio/patología , Tetralogía de Fallot/genética , Tetralogía de Fallot/patología , Apoptosis , Secuencia de Bases , Proliferación Celular , Estudios de Cohortes , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Frecuencia de los Genes , Humanos , Datos de Secuencia Molecular , Herencia Multifactorial , Mutación , Miocardio/metabolismo , Análisis de Secuencia de ADN , Tetralogía de Fallot/sangre
10.
J Heart Valve Dis ; 25(1): 66-71, 2016 01.
Artículo en Inglés | MEDLINE | ID: mdl-27989087

RESUMEN

BACKGROUND: A straightforward tricuspid valve (TV) repair technique was used to treat either moderate or severe functional (normal valve with dilated annulus) or for primary/organic (Ebstein's anomaly, leaflet retraction/tethering and chordal malposition/tethering, with annular dilatation) TV incompetence, and its long-term outcome assessed. METHODS: A double-orifice valve technique was employed in 91 patients (mean age 52.6 ± 23.2 years; median age 56 years; range: 0.6-82 years) with severe tricuspid regurgitation. Among the patients, three had post-transplant iatrogenic chordal rupture, five had infective endocarditis, 11 had mitral valve insufficiency, 23 had Ebstein's anomaly, and 47 had isolated severe TV incompetence. The basic principle was to reduce the distance between the coapting leaflets, wherein the most mobile leaflet could coapt to the opposite leaflet, by creating two orifices, ensuring valve competence. The TV repair was performed through a median sternotomy or right anterior thoracotomy in the fifth intercostal space under cardiopulmonary bypass. The degree and extent of creating a double-valve orifice was determined by considering the minimal body surface area (BSA)-related acceptable TV diameter. Repair was accomplished by passing pledgeted mattress sutures from the middle of the true anterior annulus to a spot on the opposite septal annulus, located approximately two-thirds of the length of the septal annulus to avoid injury to the bundle of His. The annular apposition divides the TV into a larger anterior and a smaller posterior orifices, enabling valve closure, on both sides. In adults, the diameter of the anterior valve orifice should be 23-25 mm, and the posterior orifice 15-18 mm; thus, the total valve orifice area is 5-6 cm2. In children, the total valve orifice should be a standard deviation of 1.7 mm for a BSA of <1. 0m2, and 1.5 mm for a BSA of >1.0m2. RESULTS: During a mean follow up of 8.7 ± 1.34 years (median 10 years; range: 1.5-25.9 years) there have been no reoperations for TV insufficiency or stenosis. Reoperations on three patients (mean age 42.5 ± 8.7 years) were indicated for aortic valve replacement at 14 months postoperatively (n = 1) and for assist device implantation (n = 2) who eventually underwent heart transplant at 18 and 20 months after TV repair, respectively. The cumulative 12-year survival rate was 86.9%. CONCLUSIONS: This double-orifice technique is technically a straightforward repair to abolish TV incompetence with highly satisfactory results, particularly in patients with severe annular dilatation or with leaflet and chordal tethering. In the present series, the technique provided no pitfalls (if the location of the conduction system was borne in mind), requiring only a gentle placement of sutures. It also led to no residual regurgitation or reoperation during the follow up period.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Técnicas de Sutura , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/métodos , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/diagnóstico , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/mortalidad
11.
Artif Organs ; 40(5): 470-9, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-26581834

RESUMEN

Minimizing the systemic inflammatory response caused by cardiopulmonary bypass is a major concern. It has been suggested that the perfusion temperature affects the inflammatory response. The aim of this prospective study was to compare the effects of moderate hypothermia (32°C) and normothermia (36°C) during cardiopulmonary bypass on markers of the inflammatory response and clinical outcomes (time on ventilator) after surgical closure of ventricular septal defects. During surgical closure of ventricular septal defects under cardiopulmonary bypass, 20 children (median age 4.9 months, range 2.3-38 months; median weight 7.2 kg, range 5.2-11.7 kg) were randomized to a perfusion temperature of either 32°C (Group 1, n = 10) or 36°C (Group 2, n = 10). The clinical data and blood samples were collected before cardiopulmonary bypass, directly after aortic cross-clamp release, and 4 and 24 h after weaning from cardiopulmonary bypass. Time on ventilation as primary outcome did not differ between the two groups. Other clinical outcome parameters like fluid balance or length of stay in the intensive care were also similar in the two groups. Compared with Group 2, Group 1 needed significantly higher and longer inotropic support (P < 0.001). In Group 1, two infants had junctional ectopic tachycardia, and another had a pulmonary hypertensive crisis. Perfusion temperature did not influence cytokine release, organ injury, or coagulation. Cardiopulmonary bypass temperature does not influence time on ventilation or inflammatory marker release. However, in the present study, with a small patient cohort, patients operated under hypothermic bypass needed higher and longer inotropic support. The use of hypothermic cardiopulmonary bypass in infants and children should be approached with care.


Asunto(s)
Puente Cardiopulmonar/métodos , Defectos del Tabique Interventricular/cirugía , Hipotermia Inducida/métodos , Coagulación Sanguínea , Citocinas/sangre , Femenino , Defectos del Tabique Interventricular/sangre , Defectos del Tabique Interventricular/complicaciones , Humanos , Lactante , Inflamación/sangre , Inflamación/complicaciones , Masculino , Estudios Prospectivos , Síndrome de Respuesta Inflamatoria Sistémica/sangre , Síndrome de Respuesta Inflamatoria Sistémica/complicaciones , Resultado del Tratamiento
12.
N Engl J Med ; 376(5): 487-489, 2017 02 02.
Artículo en Inglés | MEDLINE | ID: mdl-28146667
14.
Crit Care ; 19: 131, 2015 Mar 31.
Artículo en Inglés | MEDLINE | ID: mdl-25886728

RESUMEN

INTRODUCTION: In recent years the development of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has increasingly been perceived as a separate disease entity. About possible trigger mechanisms of SSC-CIP has been speculated, systematic investigations on this issue are still lacking. The purpose of this study was to evaluate the prevalence and influence of promoting factors. METHODS: Temporality, consistency and biological plausibility are essential prerequisites for causality. In this study, we investigated the temporality and consistency of possible triggers of SSC-CIP in a large case series. Biological plausibility of the individual triggers is discussed in a scientific context. SSC-CIP cases were recruited retrospectively from 2633 patients who underwent or were scheduled for liver transplantation at the University Hospital Charité, Berlin. All patients who developed secondary sclerosing cholangitis in association with intensive care treatment were included. Possible trigger factors during the course of the initial intensive care treatment were recorded. RESULTS: Sixteen patients (68% males, mean age 45.87 ± 14.64 years) with a confirmed diagnosis of SSC-CIP were identified. Of the 19 risk factors investigated, particularly severe hypotension with a prolonged decrease in mean arterial blood pressure (MAP) to <65 mmHg and systemic inflammatory response syndrome (SIRS) were established as possible triggers of SSC-CIP. The occurrence of severe hypotension appears to be the first and most significant step in the pathogenesis. It seems that severe hypotension has a critical effect on the blood supply of bile ducts when it occurs together with additional microcirculatory disturbances. CONCLUSIONS: In critically ill patients with newly acquired cholestasis the differential diagnosis of SSC-CIP should be considered when they have had an episode of haemodynamic instability with a prolonged decrease in MAP, initial need for large amounts of blood transfusions or colloids, and early development of a SIRS.


Asunto(s)
Colangitis Esclerosante/etiología , Enfermedad Crítica/terapia , Adulto , Anciano , Colangitis Esclerosante/diagnóstico , Colangitis Esclerosante/terapia , Cuidados Críticos , Femenino , Humanos , Hipotensión/complicaciones , Hígado/patología , Trasplante de Hígado , Masculino , Microcirculación , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Síndrome de Respuesta Inflamatoria Sistémica/complicaciones , Resultado del Tratamiento
15.
J Heart Valve Dis ; 24(2): 220-7, 2015 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-26204690

RESUMEN

BACKGROUND AND AIM OF THE STUDY: An increasing number of young adult patients are choosing bioprostheses for aortic valve replacement (AVR). In this context, the Ross operation deserves renewed consideration as an alternative biological substitute. After both the Ross procedure and bioprosthetic AVR, reoperation rates remain a concern and may be related to age at surgery. Herein are reported details of freedom from reoperation after the Ross procedure for different age groups. METHODS: The reoperation rates of 1,925 patients (1,444 males, 481 females; mean age 41.2 ± 15.3 years) from the German Ross registry with a mean follow up of 7.4 ± 4.7 years (range: 0.00-18.51 years; total 12,866.6 patient-years) were allocated to three age groups: group I < 40 years; group II 40-60 years; and group III > 60 years. RESULTS: At 10 years (respectively 15 years) of follow up, freedom from reoperation was 86% (76%) in group I, 93% (85%) in group II, and 89% (83%) in group III. CONCLUSION: There is some evidence that, at least during the first 10 and 15 years after AVR, the Ross procedure provides a significantly lower reoperation rate in young adult and middle-aged patients aged < 60 years. This information may be of interest to the patients' or physicians' decision-making for aortic valve surgery.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Enfermedades de las Válvulas Cardíacas/cirugía , Adulto , Bioprótesis , Femenino , Alemania , Enfermedades de las Válvulas Cardíacas/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Reoperación/estadística & datos numéricos , Adulto Joven
17.
Eur Heart J ; 35(19): 1263-74, 2014 May 14.
Artículo en Inglés | MEDLINE | ID: mdl-24497345

RESUMEN

AIMS: Intra-myocardial transplantation of CD133(+) bone marrow stem cells (BMC) yielded promising results in clinical pilot trials. We now performed the double-blinded, randomized, placebo-controlled CARDIO133 trial to determine its impact on left ventricular (LV) function and clinical symptoms. METHODS AND RESULTS: Sixty patients with chronic ischaemic heart disease and impaired LV function (left ventricular ejection fraction, LVEF <35%) were randomized to undergo either coronary artery bypass grafting (CABG) and injection of CD133(+) BMC in the non-transmural, hypokinetic infarct border zone (CD133), or CABG and placebo injection (placebo). Pre-operative LVEF was 27 ± 6% in CD133 patients and 26 ± 6% in placebo patients. Outcome was assessed after 6 months, and the primary endpoint was LVEF measured by cardiac magnetic resonance imaging (MRI) at rest. The incidence of adverse events was similar in both groups. There was no difference in 6-min walking distance, Minnesota Living with Heart Failure score, or Canadian Cardiovascular Society (CCS) class between groups at follow-up, and New York Heart Association class improved more in the placebo group (P = 0.004). By cardiac MRI, LVEF at 6 months was 33 ± 8% in the placebo group and 31 ± 7% in verum patients (P = 0.3), with an average inter-group difference of -2.1% (95% CI -6.3 to 2.1). Systolic or diastolic LV dimensions at 6 months were not different, either. In the CD133 group, myocardial perfusion at rest recovered in more LV segments than in the placebo group (9 vs. 2%, P < 0.001). Scar mass decreased by 2.2 ± 5 g in CD133(+) patients (P = 0.05), but was unchanged in the placebo group (0.3 ± 4 g, P = 0.7; inter-group difference in change = 2 g (95% CI -1.1 to 5)). By speckle-tracking echocardiography, cell-treated patients showed a better recovery of regional wall motion when the target area was posterior. CONCLUSION: Although there may be some improvements in scar size and regional perfusion, intra-myocardial injection of CD133(+) BMC has no effect on global LV function and clinical symptoms. Improvements in regional myocardial function are only detectable in patients with posterior infarction, probably because the interventricular septum after anterior infarction is not accessible by trans-epicardial injection. CLINICAL TRIAL REGISTRATION: This trial was registered at http://www.clinicaltrials.gov under NCT00462774.


Asunto(s)
Trasplante de Médula Ósea/métodos , Puente de Arteria Coronaria/métodos , Corazón/fisiología , Isquemia Miocárdica/terapia , Regeneración/fisiología , Trasplante de Células Madre/métodos , Antígeno AC133 , Antígenos CD , Trasplante de Médula Ósea/mortalidad , Terapia Combinada/métodos , Terapia Combinada/mortalidad , Puente de Arteria Coronaria/mortalidad , Femenino , Glicoproteínas , Humanos , Inyecciones Intralesiones , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/mortalidad , Péptidos , Trasplante de Células Madre/mortalidad , Trasplante Autólogo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/terapia
18.
Circulation ; 128(11 Suppl 1): S14-23, 2013 Sep 10.
Artículo en Inglés | MEDLINE | ID: mdl-24030398

RESUMEN

BACKGROUND: Left ventricular assist devices (LVADs) provide better outcome than biventricular devices, but it is a challenge to predict the impact of LV mechanical unloading on postoperative right ventricular (RV) function preoperatively. We assessed the load dependency in RV performance before and after LVAD implantation aiming to improve preoperative decision making. METHODS AND RESULTS: Laboratory, echocardiography, and right heart catheterization data collected from 205 patients before LVAD implantation were tested for relationship with postoperative RV function. Comparing patients with different time-course of RV function after LVAD implantation, we found significant differences (P<0.01) in preoperative RV end-diastolic short-/long-axis and long-axis/length-area ratios, tricuspid annulus peak systolic velocity, RV peak longitudinal global systolic strain rate, systolic pressure gradient between RV and right atrium (ΔPRV-RA), tricuspid regurgitation velocity-time integral, and pulmonary arterial pressure between patients with and without postoperative RV failure. High predictive values for postoperative RV failure were found for end-diastolic short-/long-axis ratio ≥ 0.6, tricuspid annulus peak systolic velocity <8 cm/s, and peak systolic longitudinal strain rate <0.6/s in patients with maximum ΔPRV-RA <35 mm Hg. These parameters also seemed predictive for RV failure in patients with tricuspid regurgitation grade >2 and pulmonary arterial pressure <50 mm Hg. End-diastolic short-/long-axis ratio <0.6, tricuspid annulus peak systolic velocity ≥ 8 cm/s, and peak systolic longitudinal strain rate ≥ 0.6 in patients with maximum ΔPRV-RA ≥ 35 mm Hg showed high predictive values for postoperative freedom from RV failure. The RV load adaptation index seemed particularly predictive for RV function after LVAD implantation. CONCLUSIONS: RV geometry and velocity of contraction before LVAD implantation become more predictive for postoperative RV function and can improve decision making before VAD implantation if preoperative RV pressure load and tricuspid regurgitation are also considered.


Asunto(s)
Toma de Decisiones , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Función Ventricular Derecha/fisiología , Adulto , Anciano , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Ultrasonografía
19.
Transpl Int ; 27(9): 917-25, 2014 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-24853064

RESUMEN

Pediatric heart allocation in Eurotransplant (ET) has evolved over the past decades to better serve patients and improve utilization. Pediatric heart transplants (HT) account for 6% of the annual transplant volume in ET. Death rates on the pediatric heart transplant waiting list have decreased over the years, from 25% in 1997 to 18% in 2011. Within the first year after listing, 32% of all infants (<12 months), 20% of all children aged 1-10 years, and 15% of all children aged 11-15 years died without having received a heart transplant. Survival after transplantation improved over the years, and in almost a decade, the 1-year survival went from 83% to 89%, and the 3-year rates increased from 81% to 85%. Improved medical management of heart failure patients and the availability of mechanical support for children have significantly improved the prospects for children on the heart transplant waiting list.


Asunto(s)
Trasplante de Corazón/estadística & datos numéricos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Listas de Espera , Adolescente , Determinación de la Edad por el Esqueleto , Niño , Preescolar , Europa (Continente) , Estudios de Seguimiento , Política de Salud , Cardiopatías/mortalidad , Cardiopatías/cirugía , Trasplante de Corazón/mortalidad , Corazón Auxiliar , Humanos , Lactante , Estimación de Kaplan-Meier , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/organización & administración , Obtención de Tejidos y Órganos/normas , Receptores de Trasplantes/clasificación , Receptores de Trasplantes/estadística & datos numéricos , Resultado del Tratamiento , Listas de Espera/mortalidad
20.
Acta Neurochir (Wien) ; 156(9): 1729-34, 2014 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-24919800

RESUMEN

BACKGROUND: Cranial intraparenchymal hemorrhage represents a critical complication of mechanical circulatory support requiring constant antithrombotic treatment. Surgery of intraparenchymal hemorrhage under anticoagulation represents a challenge and imposes significant risks for patients. It was the aim to analyse surgical and clinical outcome of patients requiring surgical treatment due to intraparenchymal hemorrhage. METHODS: Patients with mechanical circulatory support requiring surgical therapy due to space-occupying lobar supratentorial or infratentorial hemorrhage from January 1, 2009 to January 1, 2014 were included in our study. Baseline parameters are preoperative International Normalized Ratio (INR) values, postoperative anticoagulation regiment, bleeding size and localization. Co-primary outcome parameters were the extent of hematoma evacuation and the Modified Rankin Scale at discharge from hospital. Secondary outcome parameters included rate of recurrent hemorrhage, rate of revision surgery and in-hospital mortality. RESULTS: Twelve patients (mean age 44 ± 18 years, nine supratentorial-/three infratentorial hemorrhages, 11 left ventricular assist devices, and one extracorporeal membrane oxygenation) were included. Surgical hematoma evacuation was performed in 11 patients, one patient received decompressive hemicraniectomy. Hematoma evacuation was complete in no patients, and partial in 11 patients. Initial INR was 2,7 ± 1,6. Rate of recurrent hemorrhage was 75 %. Revision surgery was performed in three patients achieving partial hematoma evacuation in two patients and complete evacuation in one patient. Modified Rankin Scale at discharge from hospital was six in nine patients (in-hospital mortality of 75 %), five in two patients and four in one patient. CONCLUSIONS: Surgical treatment of life threatening, space-occupying intraparenchymal hemorrhage under mechanical circulation support is of limited efficacy with high rates of recurrent hemorrhage and in-hospital mortality. We provide additional data that postponing anticoagulation is feasible and may lead to improved clinical outcome and survival.


Asunto(s)
Oxigenación por Membrana Extracorpórea , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Hemorragias Intracraneales/cirugía , Adulto , Anciano , Descompresión Quirúrgica , Femenino , Mortalidad Hospitalaria , Humanos , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Recurrencia
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