Bridge to transplant or recovery in cardiogenic shock in a developing country.

Background Durable mechanical support devices are prohibitively expensive in our health system and may be unsuitable for critically ill patients. CentriMag is an alternative bridge to transplantation or recovery. Methods We retrospectively reviewed 28 patients (23 males) aged 13-60 years who received CentriMag support. The etiology was ischemic in 13 (46%), dilated cardiomyopathy in 8 (29%), and others in 7 (25%). All patients were in Interagency Registry for Mechanically Assisted Circulatory Support class I, and 27 (96%) had multiorgan failure; 2 (7%) were post-cardiotomy and 12 (43%) had a previous cardiac arrest (mean arrest time 21 ± 17 min). Results Thirty-day post-implant survival was 79% (22 patients). Twenty (71%) patients were successfully bridged to transplantation or recovery. The mean support time was 40 days; 12 (43%) patients had >4-weeks' support (longest was 292 days). Eight (29%) patients died on support. Complications included bleeding in 10 (36%) cases, immediate stroke in 4 (14%), and dialysis in 8 (29%). There was no stroke during subsequent support. Eighteen (64%) patients underwent transplantation, and 17 of them were discharged. Two (7%) patients recovered and were discharged. Two-year survival was 62% ± 10%. Mean follow-up was 21 months (total follow-up 579 months). Two (7%) patients died during follow-up. All survivors were in New York Heart Association class I. Conclusions CentriMag is useful for medium-term support for cardiogenic shock in a developing country. Support for >4 weeks is feasible. The stroke rate is low during support. The major drawback is prolonged intensive care unit stay.

Reporte de dos casos clínicos de melanoma con metástasis cardíacas: ("dos caras de una misma moneda") / Melanoma with cardiac metastasis: report of two cases

A 39 year old man presented with signs of an ischemic in-farct in the territory of the medial cerebral artery. A large mobile mass was present in the left atrium and a biopsy showed tissue heavily infiltrated with fat and resection was not possible. A small lesion located at the dorsum allowed a histologic confirmation of a melanoma. The patient died 4 months after surgery. The second patient, a 34 year old woman being treated with chemotherapy for an ovarian melanoma was found to have a right atrial mass. After successful resection of the mass a metastasis of the original melanoma was confirmed and the patient remains in good condition at mid term follow up.

Experiencia clínica con 53 trasplantes cardiacos consecutivos / Clinical experience with 53 consecutive heart transplants

Introduction: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. Patients and Methods: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. Results: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). Operative technique: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. Conclusion: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

[Clinical experience with 53 consecutive heart transplants]. / Experiencia clínica con 53 trasplantes cardiacos consecutivos.

INTRODUCTION: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. PATIENTS AND METHODS: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. RESULTS: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). OPERATIVE TECHNIQUE: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. CONCLUSION: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

[Four-week Levitronix Centrimag bridge-to-transplant for post myocardial infarction cardiogenic shock. A case report]. / Puente al trasplante de 4 semanas utilizando el sistema de asistencia ventricular Levitronix Centrimag en el shock cardiogénico post-infarto al miocardio. Caso clínico.

Cardiogenic shock after myocardial infarction has a high mortality even if early revascularization is achieved. Biventricular assist devices have not been used in Chile in this critical setting. We report a case of a 55-year-old diabetic man who suffered an acute chest pain and ventricular fibrillation. Prompt outside hospital defibrillation/reanimation restored pulse and allowed emergency room transfer on mechanical ventilation. Electrocardiogram showed an anterior myocardial infarction and early revascularization was achieved by anterior descending artery angioplasty. However, severe cardiogenic shock continued in spite of inotropic and intra aortic balloon pump support. Levitronix Centrimag biventricular mechanical circulatory support was inserted during reanimation for recurrent ventricular fibrillation and the patient listed for urgent cardiac transplantation upon stabilization. Heart transplantation was performed successfully 28 days later and the patient was discharged after a 21-day recovery period. Twelve months after transplant the patient is in NYHA functional class I with normal biventricular function. Levitronix Centrimag biventricular mechanical circulatory support could be used successfully as a bridge-to-transplant for myocardial infarction cardiogenic shock.

Puente al trasplante de 4 semanas utilizando el sistema de asistencia ventricular Levitronix Centrimag® en el shock cardiogénico post-infarto al miocardio: Caso clínico / Four-week Levitronix Centrimag® bridge-to-transplant for post myocardial infarction cardiogenic shock: A case report

Cardiogenic shock after myocardial infarction has a high mortality even if early revascularization is achieved. Biventricular assist devices have not been used in Chile in this critical setting. We report a case of a 55 year-old diabetic man who suffered an acute chest pain and ventricular fibrillation. Prompt outside hospital defibrillation/ reanimation restored pulse and allowed emergency room transfer on mechanical ventilation. Electrocardiogram showed an anterior myocardial infarction and early revascularization was achieved by anterior descending artery angioplasty. However, severe cardiogenic shock continued in spite of inotropic and intra aortic balloon pump support. Levitronix Centrimag® biventricular mechanical circulatory support was inserted during reanimation for recurrent ventricular fibrillation and the patient listed for urgent cardiac transplantation upon stabilization. Heart transplantation was performed successfully 28 days later and the patient was discharged after a 21-day recovery period. Twelve months after transplant the patient is in NYHA functional class I with normal biventricular function. Levitronix Centrimag® biventricular mechanical circulatory support could be used successfully as a bridge-to-transplant for myocardial infarction cardiogenic shock.

Use of vitamins C and E as a prophylactic therapy to prevent postoperative atrial fibrillation.

Oxidative stress has been strongly involved in the underlying mechanism of atrial fibrillation, particularly in the arrhythmia occurring in patients undergoing cardiac surgery with extracorporeal circulation (postoperative atrial fibrillation). The ischemia/reperfusion injury thus occurring in the myocardial tissue contributes to the development of tissue remodeling, thought to be responsible for the functional heart impairment. Consequently, structural changes due to the cardiac tissue biomolecules attack by reactive oxygen and/or nitrogen species could account for functional changes in ion channels, transporters, membrane conductance, cytosolic transduction signals, and other events, all associated with the occurrence of arrhythmic consequences. The lack of success and significant side effects of anti-arrhythmic drugs have given rise to attempts aimed to develop alternative novel pharmacologic treatments. On this line, the biological properties of the antioxidant vitamins C and E suggest that they could decrease the vulnerability of the heart to the oxidative damage. Nevertheless, very few studies to assess their anti-arrhythmic effects have been reported in humans. The clinical and experimental evidence supporting the view that the pharmacological use of antioxidant vitamins could contribute to prevent postoperative atrial fibrillation is presented.

Prevention of atrial fibrillation following cardiac surgery: basis for a novel therapeutic strategy based on non-hypoxic myocardial preconditioning.

Atrial fibrillation is the most common complication of cardiac surgical procedures performed with cardiopulmonary bypass. It contributes to increased hospital length of stay and treatment costs. At present, preventive strategies offer only suboptimal benefits, despite improvements in anesthesia, surgical technique, and medical therapy. The pathogenesis of postoperative atrial fibrillation is considered to be multifactorial. However oxidative stress is a major contributory factor representing the unavoidable consequences of ischemia/reperfusion cycle occurring in this setting. Considerable evidence suggests the involvement of reactive oxygen species (ROS) in the pathogenic mechanism of this arrhythmia. Interestingly, the deleterious consequences of high ROS exposure, such as inflammation, cell death (apoptosis/necrosis) or fibrosis, may be abrogated by a myocardial preconditioning process caused by previous exposure to moderate ROS concentration known to trigger survival response mechanisms. The latter condition may be created by n-3 PUFA supplementation that could give rise to an adaptive response characterized by increased expression of myocardial antioxidant enzymes and/or anti-apoptotic pathways. In addition, a further reinforcement of myocardial antioxidant defenses could be obtained through vitamins C and E supplementation, an intervention also known to diminish enzymatic ROS production. Based on this paradigm, this review presents clinical and experimental evidence supporting the pathophysiological and molecular basis for a novel therapeutic approach aimed to diminish the incidence of postoperative atrial fibrillation through a non-hypoxic preconditioning plus a reinforcement of the antioxidant defense system in the myocardial tissue.

Influencia del sistema nitridérgico en la respuesta contráctil a fenilefrina de anillos de vasos usados en revascularización coronaria / Modification of phenylephrine induced contraction of human vessel rings by L-arginine and L-arginine methyl ester

Background: Endothelial dysfunction is associated to a lower production of nitric oxide and a reduction of endothelium mediated vasodilation. Aim: To study the effects of pharmacological agents that modify nitric oxide synthetase (NOS) activity on tension changes induced by phenylephrine in rings of internal mammary and radial arteries and saphenous vein. Material and methods: Vessel rings of 7 to 10 mm length were obtained from 32 patients subjected to coronary vascular surgery Fourteen samples of radial artery, 12 samples of internal mammary artery and 15 samples of saphenous vein were obtained. A maximal contraction was induced with KC1 and dose response curves for phenylephrine (FE) in the absence or presence of L-arginine and L-arginine methyl ester (L-NAME), were constructed. Results: The tension induced by FE in internal mammary artery and saphenous vein reached a maximum, near 90 percent of 80 mM KCl-induced contraction, but in the radial artery, it reached a maximum of 63 percent (p <0.05). In all vessels, the dose response curves were significantly shifted to the right by L-arginine and to the íeft by L-NAME. Conclusions: Pre-incubation of human rings with L-ARG or L-NAME, changed the response to FE induced contraction, which may be related to different degrees of endothelial nitric oxide production or NO sensitivity. The basal NO production in radial artery seems to be larger than the other vessels.

[Modification of phenylephrine induced contraction of human vessel rings by L-arginine and L-arginine methyl ester]. / Influencia del sistema nitridérgico en la respuesta contráctil a fenilefrina de anillos de vasos usados en revascularización coronaria.

BACKGROUND: Endothelial dysfunction is associated to a lower production of nitric oxide and a reduction of endothelium mediated vasodilation. AIM: To study the effects of pharmacological agents that modify nitric oxide synthetase (NOS) activity on tension changes induced by phenylephrine in rings of internal mammary and radial arteries and saphenous vein. MATERIAL AND METHODS: Vessel rings of 7 to 10 mm length were obtained from 32 patients subjected to coronary vascular surgery Fourteen samples of radial artery, 12 samples of internal mammary artery and 15 samples of saphenous vein were obtained. A maximal contraction was induced with KC1 and dose response curves for phenylephrine (FE) in the absence or presence of L-arginine and L-arginine methyl ester (L-NAME), were constructed. RESULTS: The tension induced by FE in internal mammary artery and saphenous vein reached a maximum, near 90% of 80 mM KCl-induced contraction, but in the radial artery, it reached a maximum of 63% (p <0.05). In all vessels, the dose response curves were significantly shifted to the right by L-arginine and to the left by L-NAME. CONCLUSIONS: Pre-incubation of human rings with L-ARG or L-NAME, changed the response to FE induced contraction, which may be related to different degrees of endothelial nitric oxide production or NO sensitivity. The basal NO production in radial artery seems to be larger than the other vessels.

Efecto agudo de las estatinas sobre la relajación vascular in vitro mediada por acetilcolina y nitroprusiato en vasos usados en la revascularización coronaria / Acute effect of statins on acetylcholine and nitroprusside induced vascular relaxation of vessels used for revascularization purposes

Antecedentes: Uno de los efectos pleiotrópicos de las estatinas es su capacidad de inducir relajación vascular tanto in Vitro como in Vivo cuando son administradas crónicamente, pero el efecto agudo en los vasos no ha sido estudiado en detalle. Objetivos: Evaluar los efectos agudos de las estatinas en la relajación vascular in vitro mediada por acetilcolina (ACh) y nitroprusiato en vasos usados en revascularización coronaria. Método: Se analizaron segmentos de vasos obtenidos de pacientes programados para cirugía de revascularización coronaria. Cada segmento de arteria radial, mamaria y vena safena fue dividido en dos, uno de ellos incubado durante dos horas con estatinas y el otro con solución buffer. Luego, se contrajo cada vaso con 80 mM de KCl y posteriormente con 10-4 M de noradrenalina seguido de administración de dosis acumulativas de ACh para inducir la relajación del vaso. Después de lavados repetidos, se contrae con la misma dosis de noradrenalina y se relaja con dosis creciente de nitroprusiato (NP). Resultados: La administración de KCl produjo una mayor contracción, aunque no significativa, en arterias radiales en relacióna los otros vasos, tanto en los incubados con estatinas como el grupo control. La noradrenalina produjo una mayor contracción no significativa en venas safenas; sin embargo no hubo diferencias entre los segmentos incubados con y sin estatinas. La vasodilatación por acetilcolina no se vio afectada por estatinas. La vasodilatación inducida por nitroprusiato no se modificó en presencia de estatinas en arterias radiales o mamaria. Sin embargo el tratamiento con estatina disminuyó significativamente la relajación inducida por nitroprusiato en la vena safena (p<0,05). Conclusión: Los resultados de este trabajo demuestran una respuesta diferencial de los vasos usados en revascularización coronaria frente al efecto agudo de estatina.

Prevención de deficiencia de hierro en lactantes de bajo peso de nacimiento: comparación de dos métodos de administrar hierro / Prevention of iron deficiency in low birth weight infants: comparison of 2 methods of prophylactic iron administration

97 lactantes de bajo peso de nacimiento fueron seguidos en forma prospectiva desde los 3 hasta los 12 meses de edad, para comparar dos formas de administrar hierro. El grupo A recibió una leche fortificada con sulfato ferroso y ácido ascórbico que suministra Fe++ en dosis de 2,5 mg/kg/día, en el volumen de leche diario. El grupo B recibió una leche similar, pero sin fortificación, y se agregó sulfato ferroso medicinal (Fe++ 2,5 mg/kg/día) en una o dos dosis. Se compararon parámetros de nutrición de hierro en ambos grupos con la prueba t student. Resultados: al inicio, y a los 3 meses de estudio, se observaron valores hematológicos similares en ambos grupos para hemoglobina, saturación de tranferrina y ferritina, en tanto que la protoporfirina tuvo un valor significativamente mayor de hemoglobina y saturación de transferrina en el grupo A, en tanto que la protoporfirina a los 6 meses fue igual y a los 9 meses tuvo un valor significativamente menor en el grupo A. La ferritina fue similar durante todo el estudio en ambos grupos. Estos hallazgos indican una mejor nutrición de hierro para el grupo A de leche fortificada con hierro. En el grupo B de hierro medicinal hubo una progresiva disminución en la administración del medicamento a medida que el estudio progresaba, indicando que no es un procedimiento adecuado para suministrar hierro por un período prolongado de tiempo. Los resultados también muestran que la dosis de Fe++ debe ser aumentada antes de los 6 a 9 meses de edad, para evitar carencia de hierro en un subgrupo de lactantes de bajo peso de nacimiento

Diagnóstico de adenopatías en niños: rol de la punción con aguja fina / Fine needle aspiration biopsy for the diagnosis of lymphadenopathy in children

Background: Lymphadenopathy in children can be a challenging clinical situation that requires a careful approach. Aim: To report the experience with fine needle aspiration biopsy for the diagnosis of lymphadenopathy. Patients and methods: Analysis of 95 pediatric patients, aged 3 months to 19 years old, referred by primary care physicians for the study of lymphadenopathy. All were subjected to a complete medical examination, laboratory tests and fine needle aspiration biopsy. Results: Seventy seven per cent of enlarged lymph nodes were located in the neck. Fine needle aspiration showed a hyperplastic adenitis in 44 patients (46 percent). In 13 patients, an infectious adenitis, sometimes suppurated was observed. In 9 patients a BCG or tuberculous adenitis with caseum was found. In 13 patients, citology disclosed a non lymphatic mass, in four patients a Hodgkin discase and in one, malignant cells of unknown origin. Four patients had a normal lymph node and in 2 the sample was insufficient for cytological analysis. Conclusions. Fine needle aspiration biopsy is a simple and safe diagnostic method for lymphadenopathy in children

Púrpura trombocitopénica idiopática aguda en niños: un estudio prospectivo de tratamiento con y sin prednisona / Acute idiopathic thrombocytopenic purpura in children: a prospective study comparing treatment with or without prednisone

Se estudian prospectivamente 52 pacientes con púrpura trombocitopénica idiopática (PTI), cuyas edades fluctuaron entre un mes y 19 años, para evaluar la respuesta al tratamiento randomizado con y sin prednisona (PDN). 27 pacientes recibieron PDN en dosis mg/kg/día durante un mes (grupo I), y los que normalizaron el recuento plaquetario, lo hicieron en una mediana de 33 días. 25 pacientes fueron el grupo control (grupo 2), sin tratamiento, y los que normalizaron sus plaquetas, lo hicieron en una mediana de 30 días. 22 pacientes, en número equivalente de cada uno de los grupos, no recuperaron sus plaquetas en el período de 6 meses, transformándose la enfermedad en una PTI crónica. Se concluye que la normalización del recuento plaquetario es independiente del valor inicial y del uso o no uso de PDN, no modificando este medicamento la evolución natural de la enfermedad. finalmente la evolución de estos pacientes orienta a que el reposo es una medida terapéutica importante para evitar los riesgos de hemorragias