Utilidad de la escala INTERMACS para estratificar el pronóstico tras el trasplante cardiaco urgente / Usefulness of the INTERMACS scale for predicting outcomes after urgent heart transplantation

Introducción y objetivos. Analizar el valor pronóstico de la escala INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) en pacientes tratados con trasplante cardiaco urgente. Métodos. Análisis retrospectivo de 111 pacientes tratados con trasplante cardiaco urgente en nuestro centro entre abril de 1991 y octubre de 2009. Se asignó retrospectivamente a los pacientes a tres niveles de la escala INTERMACS en función de su situación clínica previa al trasplante cardiaco. Resultados. Los pacientes del grupo INTERMACS 1 (n=31) presentaban mayor frecuencia de cardiopatía isquémica (p=0,03) y shock tras cardiotomía (p=0,02) que los pacientes del grupo INTERMACS 2 (n=55) y los pacientes del grupo INTERMACS 3–4 (n=25), así como mayores dosis de catecolaminas (p=0,001), mayor empleo de ventilación mecánica (p<0,001), balón de contrapulsación (p=0,002) y dispositivos de asistencia ventricular (p=0,002) y mayores tasas de infección preoperatoria (p=0,015). El grupo INTERMACS 1 también mostraba mayores cifras de presión venosa central (p=0,02), GOT (p=0,002), GPT (p=0,006) y creatinina (p<0,001) y menores cifras de hemoglobina (p=0,008) y aclaramiento de creatinina (p=0,001). Tras el trasplante cardiaco, los pacientes del grupo INTERMACS 1 presentaron mayores incidencias de fracaso primario del injerto (p=0,03) y necesidad de terapia de sustitución renal (p=0,004), y su supervivencia a largo plazo fue menor que la de los pacientes de los grupos INTERMACS 2 (log rank=5,1; p=0,023; razón de riesgos [HR]=3,1; intervalo de confianza [IC] del 95%, 1,4-6,8) e INTERMACS 3-4 (log rank=6,1; p=0,013; HR=4; IC del 95%, 1,3-12,3). Conclusiones. Nuestros resultados indican que la escala INTERMACS resulta útil para estratificar el pronóstico postoperatorio tras el trasplante cardiaco urgente(AU)

Introduction and objectives: Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). Methods: Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. Results: Patients at the INTERMACS 1 level (n = 31) more frequently had ischemic heart disease (P = .03) and post-cardiothomy shock (P = .02) than patients at the INTERMACS 2 (n = 55) and INTERMACS 3-4 (n = 25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P = .001), a higher frequency of use of mechanical ventilation (P < .001), intraaortic balloon (P = .002) and ventricular assist devices (P = .002), and a higher frequency of preoperative infection (P = .015). The INTERMACS 1 group also presented higher central venous pressure (P = .02), AST (P = .002), ALT (P = .006) and serum creatinine (P < .001), and lower hemoglobin (P = .008) and creatinine clearance (P = .001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P = .03) and postoperative need for renal replacement therapy (P = .004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P = .023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p = 0.013; HR 6.8, IC 95% 1.2-39.1). Conclusions: Our results suggest that the INTERMACS scalemay be a useful tool to stratify postoperative prognosis after urgent HT(AU)

Usefulness of the INTERMACS Scale for predicting outcomes after urgent heart transplantation.

INTRODUCTION AND OBJECTIVES: Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). METHODS: Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. RESULTS: Patients at the INTERMACS 1 level (n=31) more frequently had ischemic heart disease (P=.03) and post-cardiothomy shock (P=.02) than patients at the INTERMACS 2 (n=55) and INTERMACS 3-4 (n=25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P=.001), a higher frequency of use of mechanical ventilation (P<.001), intraaortic balloon (P=.002) and ventricular assist devices (P=.002), and a higher frequency of preoperative infection (P=.015). The INTERMACS 1 group also presented higher central venous pressure (P=.02), AST (P=.002), ALT (P=.006) and serum creatinine (P<.001), and lower hemoglobin (P=.008) and creatinine clearance (P=.001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P=.03) and postoperative need for renal replacement therapy (P=.004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P=.023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p=0.013; HR 6.8, IC 95% 1.2-39.1). CONCLUSIONS: Our results suggest that the INTERMACS scale may be a useful tool to stratify postoperative prognosis after urgent HT.

Respiratory physiotherapy and incidence of pulmonary complications in off-pump coronary artery bypass graft surgery: an observational follow-up study.

BACKGROUND: Heart surgery is associated with an occurrence of pulmonary complications. The aim of this study was to determine whether pre-surgery respiratory physiotherapy reduces the incidence of post-surgery pulmonary complications. METHODS: Observational study of 263 patients submitted to off-pump coronary artery bypass grafting (CABG) surgery at the A Coruña University Hospital (Spain). 159 (60.5%) patients received preoperative physiotherapy. The fact that patients received preoperative physiotherapy or not was related to whether they were admitted to the cardiac surgery unit or to an alternative unit due to a lack of beds. A physiotherapist provided a daily session involving incentive spirometry, deep breathing exercises, coughing and early ambulation. A logistic regression analysis was carried out in order to identify variables associated with pulmonary complications. RESULTS: Both groups of patients (those that received physiotherapy and those that did not) were similar in age, sex, body mass index, creatinine, ejection fraction, number of affected vessels, O2 basal saturation, prevalence of diabetes, dyslipidemia, exposure to tobacco, age at smoking initiation, number of cigarettes/day and number of years as a smoker. The most frequent postoperative complications were hypoventilation (90.7%), pleural effusion (47.5%) and atelectasis (24.7%). In the univariate analysis, prophylactic physiotherapy was associated with a lower incidence of atelectasis (17% compared to 36%, p = 0.01). After taking into account age, sex, ejection fraction and whether the patients received physiotherapy or not, we observed that receiving physiotherapy is the variable with an independent effect on predicting atelectasis. CONCLUSION: Preoperative respiratory physiotherapy is related to a lower incidence of atelectasis.

[Chronic anemia in heart transplant patients: prevalence, predisposing factors and prognostic significance]. / Anemia crónica en el trasplante cardiaco. Prevalencia, factores predisponentes y significado pronóstico.

INTRODUCTION AND OBJECTIVES: Data on chronic anemia following heart transplantation (HT) are scarce and contradictory. Our aims were to determine the prevalence of chronic anemia after HT, to identify predisposing factors for the condition at 12 months, and to evaluate its influence on medium-term and long-term survival. METHODS: Retrospective analysis of patients who underwent HT between 1991 and 2005 (n=457). Chronic anemia was defined as a hemoglobin level <12 g/dL. RESULTS: The prevalence of post-HT chronic anemia was 75.5% at 1 month, 31% at 12 months, and 26.2% at 120 months. The condition was significantly more prevalent among women than men. Predisposing factors for chronic anemia 1 year post-HT were mild-to-moderate chronic renal failure (i.e., creatinine level >1.5 mg/dL; odds ratio [OR]=2.8; 95% confidence interval [CI], 1.5-5.0), female sex (OR=6.4; 95% CI, 3.1-13.2), and immunosuppression with mycophenolate mofetil compared with azathioprine (OR=2.6;, 95% CI, 1.4-4.8). The prevalence of chronic anemia 12 months after HT was independent of the donor's sex, the recipient's age, the etiology of the recipient's heart failure, diabetes mellitus, mild-to-moderate graft rejection, cytomegalovirus infection, and angiotensin-converting enzyme inhibitor treatment. The presence of chronic anemia 12 months after HT did not influence either long-term survival (mean, 11.5 years with chronic anemia vs. 13.0 years without) or actuarial survival. CONCLUSIONS: Post-HT chronic anemia is common, but improves with time and treatment. Predisposing factors for the condition 1 year post-HT include chronic renal failure, female sex, and immunosuppression with mycophenolate mofetil. The presence of chronic anemia does not appear to influence long-term survival.

Anemia crónica en el trasplante cardiaco. Prevalencia, factores predisponentes y significado pronóstico / Chronic anemia in heart transplant patients: prevalence, predisposing factors and prognostic significance

Introducción y objetivos. La información disponible sobre anemia crónica (AC) en pacientes con trasplante cardiaco (TC) es escasa y discordante. Nuestro objetivo fue estudiar la prevalencia de AC en pacientes post-TC, factores predisponentes de AC a 12 meses y su significado pronóstico a medio y largo plazo. Métodos. Análisis retrospectivo de pacientes con TC entre 1991 y 2005 (n = 457). AC fue definida como hemoglobina < 12 g/dl. Resultados. La prevalencia de AC post-TC fue del 75,5% a 1 mes, el 31% a los 12 meses y el 26,2% a los 120 meses, significativamente más prevalente en mujeres que en varones. Factores predisponentes de AC a 12 meses: insuficiencia renal crónica (IRC) leve-moderada (creatinina > 1,5 mg/dl) (odds ratio [OR] = 2,8; intervalo de confianza [IC] del 95%, 1,5-5); sexo femenino (OR = 6,4; IC del 95%, 3,1-13,2), e inmunosupresión con micofenolato mofetilo (MMF) respecto a azatioprina (OR = 2,6; IC del 95%, 1,4-4,8). La prevalencia de AC 1 año tras el TC no se relacionó con el sexo del donante, la edad del receptor, la cardiopatía del receptor, la diabetes mellitus, el rechazo leve o moderado del injerto (≥ 3A), infección por citomegalovirus o tratamiento con inhibidores de la enzima de conversión de angiotensina. Tener AC a 1 año del TC no supuso diferencias en la supervivencia a largo plazo (tiempo de vida medio con AC, 11,5 años y sin AC, 13 años) ni en la supervivencia actuarial. Conclusiones. La AC post-TC es un problema frecuente que mejora con el tiempo y el tratamiento. La IRC, el sexo femenino y la inmunosupresión con MMF predisponen a AC a los 12 meses del TC. Tener AC no parece influir en la supervivencia a largo plazo (AU)

Introduction and objectives. Data on chronic anemia following heart transplantation (HT) are scarce and contradictory. Our aims were to determine the prevalence of chronic anemia after HT, to identify predisposing factors for the condition at 12 months, and to evaluate its influence on medium-term and long-term survival. Methods. Retrospective analysis of patients who underwent HT between 1991 and 2005 (n=457). Chronic anemia was defined as a hemoglobin level 1.5 mg/dL; odds ratio [OR]=2.8; 95% confidence interval [CI], 1.5­5.0), female sex (OR=6.4; 95% CI, 3.1­13.2), and immunosuppression with mycophenolate mofetil compared with azathioprine (OR=2.6;, 95% CI, 1.4­4.8). The prevalence of chronic anemia 12 months after HT was independent of the donor's sex, the recipient's age, the etiology of the recipient's heart failure, diabetes mellitus, mild-to-moderate graft rejection, cytomegalovirus infection, and angiotensin-converting enzyme inhibitor treatment. The presence of chronic anemia 12 months after HT did not influence either long-term survival (mean, 11.5 years with chronic anemia vs. 13.0 years without) or actuarial survival. Conclusions. Post-HT chronic anemia is common, but improves with time and treatment. Predisposing factors for the condition 1 year post-HT include chronic renal failure, female sex, and immunosuppression with mycophenolate mofetil. The presence of chronic anemia does not appear to influence long-term survival (AU)

Restauración ventricular: Un nuevo concepto diagnóstico y terapéutico en los pacientes con miocardiopatía isquémica

There is a very important structure/function relationship of the intact ventricles. Postinfarction left ventricular remodeling is characterized by ventricular dilatation and abnormal geometry leading to systolic and diastolic dysfunction. Association of mitral regurgitation with ischemic cardiomyopathy increases the degree of heart failure. In the last years, the concept of ventricular restoration has been introduced. This is a new diagnostic and therapeutic approach for patients in heart failure. MRI studies are of great importance for evaluation, indication and follow up of these patients. The surgical approach to congestive heart failure is therefore a trilogy to deal the vessels, mitral valve, and reduce the ventricle.

La eficiencia del corazón como bomba está íntimamente ligada a la estructura y disposición de sus fibras musculares. Debemos considerar el proceso de remodelado ventricular, tras un daño miocárdico, como un elemento etiopatogénico de la insuficiencia cardíaca. Dentro de este contexto, el desarrollo de insuficiencia mitral funcional dispara la sintomatología del paciente y empeora su pronóstico. En los últimos años, se ha introducido el concepto de restauración ventricular como una nueva aproximación diagnóstica y terapéutica en el paciente con insuficiencia cardíaca. La resonancia magnética nuclear se ha convertido en la exploración principal para el diagnóstico y seguimiento de estos pacientes. Desde el punto de vista quirúrgico, debemos entender el abordaje de estos pacientes como una trilogía, hay que actuar sobre las arterias coronarias, reparar la válvula mitral si existe una insuficiencia al menos moderada, y realizar una reducción del volumen ventricular.

Cirugía coronaria en la tercera edad / Coronary bypass surgery in the elderly

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