Postoperative management and nursing care after implantation of a total artificial heart: Scoping review.

INTRODUCTION: End-stage heart failure (HF) is a condition whose only successful long-term treatment, with a survival of more than 10 years, is heart transplantation. However, limited organ availability and the progressive increase in the number of patients with advanced HF have served as an impetus for the development of implantable mechanical assistive devices. AIM: To provide an overview of postoperative management and nursing care after the implementation of a Total Artificial Heart (TAH). METHODS: A scoping review was carried out by consulting the PUBMED, CINAHL, and COCHRANE databases. From all the documents located, information was extracted on the date of publication, country of publication, type of study, and results of interest to answer the research question. In addition, the degree of recommendation was identified. RESULTS: Twenty-three documents were included in the scoping review. Results were classified in relation to: 1) description of the CAT SynCardia®; 2) nursing care in the immediate postoperative period (management of the device and management of hematological, infectious, nephrological, nutritional complications, related to immobilization, sleep-rest disturbances, psychological disorders, and patient and family education); and 3) follow-up at home. CONCLUSIONS: The complexity of implantation of the TAH, the multiple related complications that can arise during this process, both in the immediate post-operative and late, require a standardised and multidisciplinary management. The absence of standardised protocols raises the need for future studies to measure the effectiveness of care in patients with TAH. A multidisciplinary approach is crucial. Nurses must acquire autonomy and involvement in decision-making and develop competencies to address the patient's and family's physiological and psychosocial needs.

Valoración del índice de reserva de perfusión miocárdica por resonancia magnética en pacientes con trasplante cardíaco / Cardiac magnetic resonance imaging myocardial perfusion reserve index in heart transplant patients

OBJETIVO: Comparar el índice de reserva de perfusión miocárdica (IRPM) medido por resonancia magnética cardíaca de estrés (RMC-estrés) con regadenosón en sujetos trasplantados frente a no trasplantados. MATERIAL Y MÉTODOS: Se compararon, de forma retrospectiva, 20 trasplantados cardíacos consecutivos, asintomáticos y sin sospecha clínica de enfermedad microvascular, a quienes se realizó RMC-estrés con regadenosón y coronariografía por TC (CTC) para descartar enfermedad vascular del injerto (EVI) respecto a 16 sujetos no trasplantados, con RMC-estrés realizada por indicación clínica, negativa para isquemia y sin signos de cardiopatía estructural. El IRPM se estimó de forma semicuantitativa tras calcular el valor de la pendiente durante la perfusión de primer paso y dividir el valor obtenido en estrés respecto al reposo. Se comparó IRPM en ambos grupos. Los pacientes con RMC-estrés positiva para isquemia o CTC con estenosis coronaria significativa fueron derivados a coronariografía convencional. RESULTADOS: Más de la mitad de los sujetos permanecieron asintomáticos durante la prueba de estrés. La RMC-estrés resultó positiva para isquemia en dos trasplantados, que se confirmó mediante CTC y coronariografía convencional. Los pacientes trasplantados presentaron menor volumen telediastólico indexado (59,3 ±15,2 ml/m2 frente a 71,4±15,9 ml/m2, p = 0,03), menor IRPM (1,35±0,19 vs. 1,6±0,28, p = 0,003 y menor respuesta hemodinámica al regadenosón que los no trasplantados (incremento medio de la frecuencia cardíaca de 13,1±5,4 lpm frente a 28,5±8,9 lpm, p < 0,001). CONCLUSIÓN: La RMC-estrés con regadenosón es una técnica segura. En ausencia de enfermedad coronaria epicárdica significativa, los trasplantados presentan menor IRPM que los no trasplantados, lo que sugiere enfermedad microvascular. En pacientes trasplantados, la respuesta hemodinámica esperable al regadenosón es menor que en no trasplantados

OBJECTIVE: To compare the myocardial perfusion reserve index (MPRI) measured during stress cardiac magnetic resonance imaging (MRI) with regadenoson in patients with heart transplants versus in patients without heart transplants. MATERIAL AND METHODS: We retrospectively compared 20 consecutive asymptomatic heart transplant patients without suspicion of microvascular disease who underwent stress cardiac MRI with regadenoson and coronary computed tomography angiography (CTA) to rule out cardiac allograft vasculopathy versus 16 patients without transplants who underwent clinically indicated stress cardiac MRI who were negative for ischemia and had no signs of structural heart disease. We estimated MPRI semiquantitatively after calculating the up-slope of the first-pass enhancement curve and dividing the value obtained during stress by the value obtained at rest. We compared MPRI in the two groups. Patients with positive findings for ischemia on stress cardiac MRI or significant coronary stenosis on coronary CTA were referred for conventional coronary angiography. RESULTS: More than half the patients remained asymptomatic during the stress test. Stress cardiac MRI was positive for ischemia in two heart transplant patients; these findings were confirmed at coronary CTA and at conventional coronary angiography. Patients with transplants had lower end-diastolic volume index (59.3±15.2 ml/m2 vs. 71.4±15.9 ml/m2 in those without transplants, p = 0.03), lower MPRI (1.35±0.19 vs. 1.6±0.28 in those without transplants, p = 0.003), and a less pronounced hemodynamic response to regadenoson (mean increase in heart rate 13.1±5.4 bpm vs. 28.5±8.9 bpm in those without transplants, p <0.001). CONCLUSION: Stress cardiac MRI with regadenoson is safe. In the absence of epicardial coronary artery disease, patients with heart transplants have lower MPRI than patients without transplants, suggesting microvascular disease. The hemodynamic response to regadenoson is less pronounced in patients with heart transplants than in patients without heart transplants

Cardiac magnetic resonance imaging myocardial perfusion reserve index in heart transplant patients. / Valoración del índice de reserva de perfusión miocárdica por resonancia magnética en pacientes con trasplante cardíaco.

OBJECTIVE: To compare the myocardial perfusion reserve index (MPRI) measured during stress cardiac magnetic resonance imaging (MRI) with regadenoson in patients with heart transplants versus in patients without heart transplants. MATERIAL AND METHODS: We retrospectively compared 20 consecutive asymptomatic heart transplant patients without suspicion of microvascular disease who underwent stress cardiac MRI with regadenoson and coronary computed tomography angiography (CTA) to rule out cardiac allograft vasculopathy versus 16 patients without transplants who underwent clinically indicated stress cardiac MRI who were negative for ischemia and had no signs of structural heart disease. We estimated MPRI semiquantitatively after calculating the up-slope of the first-pass enhancement curve and dividing the value obtained during stress by the value obtained at rest. We compared MPRI in the two groups. Patients with positive findings for ischemia on stress cardiac MRI or significant coronary stenosis on coronary CTA were referred for conventional coronary angiography. RESULTS: More than half the patients remained asymptomatic during the stress test. Stress cardiac MRI was positive for ischemia in two heart transplant patients; these findings were confirmed at coronary CTA and at conventional coronary angiography. Patients with transplants had lower end-diastolic volume index (59.3±15.2 ml/m2 vs. 71.4±15.9 ml/m2 in those without transplants, p=0.03), lower MPRI (1.35±0.19 vs. 1.6±0.28 in those without transplants, p=0.003), and a less pronounced hemodynamic response to regadenoson (mean increase in heart rate 13.1±5.4 bpm vs. 28.5±8.9 bpm in those without transplants, p <0.001). CONCLUSION: Stress cardiac MRI with regadenoson is safe. In the absence of epicardial coronary artery disease, patients with heart transplants have lower MPRI than patients without transplants, suggesting microvascular disease. The hemodynamic response to regadenoson is less pronounced in patients with heart transplants than in patients without heart transplants.

Reduction in mortality associated with secondary cytomegalovirus prophylaxis after solid organ transplantation.

BACKGROUND: Cytomegalovirus (CMV) is the most important viral pathogen in solid organ transplant (SOT) recipients. The role of secondary CMV prophylaxis in this population remains unclear. METHODS: Retrospective cohort study in a single center. SOT recipients treated for CMV infection from 2007 to 2014 were studied to determine the efficacy and safety of secondary prophylaxis and its impact on graft loss and mortality. The outcome variable was CMV replication in the first 3 months after the end of therapy. Secondary variables were crude mortality and graft lost censored at 5 years after transplantation. Propensity score for the use of secondary prophylaxis was used to control selection bias. RESULTS: Of the 126 treated patients, 103 (83.1%) received CMV secondary prophylaxis. CMV relapse occurred in 44 (35.5%) patients. The use of secondary prophylaxis was not associated with fewer relapses (34.0% in patients with prophylaxis vs 42.9% in those without prophylaxis, P = .29). After a mean follow-up of 32.1 months, graft loss was not different between both groups but patient mortality was significantly lower in patients who received secondary prophylaxis (5.8% vs 28.6%, P = .003). CONCLUSION: Secondary prophylaxis did not prevent CMV infection relapse but it was associated with improved patient survival.

Cancer Incidence in Heart Transplant Recipients With Previous Neoplasia History.

Neoplasm history increases morbidity and mortality after solid organ transplantation and has disqualified patients from transplantation. Studies are needed to identify factors to be considered when deciding on the suitability of a patient with previous tumor for heart transplantation. A retrospective epidemiological study was conducted in heart transplant (HT) recipients (Spanish Post-Heart Transplant Tumor Registry) comparing the epidemiological data, immu-nosuppressive treatments and incidence of post-HT tumors between patients with previous malignant noncardiac tumor and with no previous tumor (NPT). The impact of previous tumor (PT) on overall survival (OS) was also assessed. A total of 4561 patients, 77 PT and 4484 NPT, were evaluated. The NPT group had a higher proportion of men than the PT group (p < 0.001). The incidence of post-HT tumors was 1.8 times greater in the PT group (95% confidence interval [CI] 1.2-2.6; p < 0.001), mainly due to the increased risk in patients with a previous hematologic tumor (rate ratio 2.3, 95% CI 1.3-4.0, p < 0.004). OS during the 10-year posttransplant period was significantly lower in the PT than the NPT group (p = 0.048) but similar when the analysis was conducted after a first post-HT tumor was diagnosed. In conclusion, a history of PT increases the incidence of post-HT tumors and should be taken into account when considering a patient for HT.

The falling incidence of hematologic cancer after heart transplantation.

BACKGROUND: A number of changes in the management of heart transplantation (HT) patients have each tended to reduce the risk of post-HT hematologic cancer, but little information is available concerning the overall effect on incidence in the HT population. METHODS: Comparison of data from the Spanish Post-Heart-Transplantation Tumour Registry for the periods 1991-2000 and 2001-2010. RESULTS: The incidence among patients who underwent HT in the latter period was about half that observed in the former, with a particularly marked improvement in regard to incidence more than five yr post-HT. CONCLUSIONS: Changes in HT patient management have jointly reduced the risk of hematologic cancer in the Spanish HT population. Long-term risk appears to have benefited more than short-term risk.

Chronic renal dysfunction in maintenance heart transplant patients: the ICEBERG study.

Chronic renal dysfunction (CRD) is a major complication after heart transplantation. We sought to describe the renal function over time, to assess the risk factors associated with CRD development, and to evaluate the clinical attitudes on diagnosis and treatment of CRD. A retrospective, cross-sectional, multicenter study was conducted in 13 outpatient clinics in Spain. A total of 244 heart recipients who survived more than 2 years after transplantation were included. Post-transplantation follow-up was 7.7 years (range: 2-22 years). CRD was diagnosed in 32.4% of patients at a mean of 3.3 years after transplantation. Serum creatinine increased 0.1 ± 0.2 mg/dL per year in CRD group compared with 0.0 ± 0.2 mg/dL per year in non-CRD group (P = .003) and glomerular filtration rate decreased -1.5 ± 4.3 mL/min/1.73 m(2) per year in CRD group versus -0.1 ± 4.8 mL/min/1.73 m(2) per year in non-CRD group (P = .027). After CRD diagnosis, major changes in immunosuppression based on calcineurin inhibitors reduction were instituted in 46.8% of patients. Multivariate model identified recipient age (P < .0001), female sex (P = .0398), and time since transplant (P < .0001) as predictors of CRD. In conclusion, the prevalence of CRD in long-term heart recipient survivors was quite high. CRD was associated with nonmodifiable factors (age, gender, and time since transplant).

Fases de reconstrucción y exactitud de la tomografía computarizada para cuantificar la función y masa ventricular izquierda / Accuracy of different reconstruction intervals to quantify left ventricular function and mass in cardiac computed tomography examinations

Objetivo. Comparar los parámetros de función y masa ventricular izquierda (VI) obtenidos con reconstrucciones realizadas en intervalos del 5 y 10% del ciclo cardiaco en pacientes con trasplante cardiaco y determinar su exactitud respecto a la resonancia magnética (RM). Material y métodos. Se incluyeron 23 trasplantados cardiacos consecutivos (21 varones; edad media 60±11,7 años) a los que se realizó un estudio cardiaco mediante tomografía computarizada (TC) de doble fuente (TCDF) y RM. Se compararon los parámetros de función y masa VI obtenidos de las imágenes de TCDF reconstruidas en intervalos del 5% (0-95%) y 10% (0-90%) del ciclo cardiaco respecto a los estimados mediante RM. Los parámetros se calcularon con un software de segmentación semiautomático en TCDF y trazando los contornos manualmente en RM. En todos los individuos se estimaron la fracción de eyección (FE), los volúmenes telediastólico (VTD), telesistólico (VTS), latido (VL) y la masa miocárdica. Resultados. La cuantificación de los parámetros de función VI mediante TCDF no mostró diferencias estadísticamente significativas según el número de fases reconstruidas (p>0,05). Respecto a la RM se observó una ligera sobreestimación de VTD, VTS y masa VI al utilizar tanto intervalos del 5% (diferencia media: 11,5±25,1ml; 6,8±10,9ml, y 28,3±21,6g, respectivamente) como 10% (diferencia media: 15,3±26,3ml; 7,4±11,5ml; 29,3±18,7g, respectivamente), con diferencias no significativas para la FE y el VL. Conclusión. En pacientes con trasplante cardiaco la TCDF es una técnica que permite cuantificar la función y la masa VI prácticamente con la misma exactitud que la RM, incluso utilizando intervalos de reconstrucción del 10% (AU)

Purpose. To compare the accuracy of cardiac dual-source CT (DSCT) reconstructions obtained at 5% and 10% of the cardiac cycle and MRI for quantifying global left ventricular (LV) function and mass in heart transplant recipients. Material and methods. We prospectively included 23 heart transplant recipients (21 male, mean age 60±11.7 years) who underwent cardiac DSCT and MRI examinations. We compared LV parameters on cardiac DSCT reconstructions obtained at 5% (0%-95%) and 10% (0%-90%) intervals of the cardiac cycle and on double-oblique short-axis MR images. We determined ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and myocardial mass using commercially available semiautomated segmentation analysis software for DSCT datasets and conventional manual contour tracing for MR studies. Results. Using different reconstruction intervals to quantify LV parameters at DSCT resulted in non-significant differences (P>.05). Compared to MRI, DSCT slightly overestimated LV-EDV, ESV, and mass when both 5% (11.5±25.1ml, 6.8±10.9ml, and 28.3±21.6g, respectively) and 10% (mean difference 15.3±26.3ml, 7.4±11.5ml, and 29.3±18.7g, respectively) reconstruction intervals were used. DSCT and MRI estimates of EF and SV were not significantly different. Conclusion. In heart transplant recipients, DSCT allows reliable quantification of LV function and mass compared with MRI, even using 10% interval reconstructions (AU)

[Penetrating ascending aortic ulcer in an asymptomatic patient]. / Úlcera penetrante de aorta ascendente en un paciente asintomático.

Penetrating aortic ulcer (PAU) has been defined as an atherosclerotic plaque ulceration that breaks the internal elastic lamina of the aorta, which may progress to a wall hematoma or aortic dissection in the case of blood seeping into the middle layer. Although PAU is commonly located in the descending aorta, the involvement of the ascending aorta can be fatal. Therefore, surgery is indicated even in asymptomatic patients presenting an ascending PAU. We report on an asymptomatic patient with ascending PAU referred for replacement of the ascending aorta with a composite prosthetic graft.

Long-term survival (>20 years) following heart transplantation.

AIM: Only a few papers with patients surviving more than 15 years after heart transplantation have been reported. Herein we report the characteristics of patients transplanted between 1984 and 1989 who are long-term survivors (>20 years). Survival after transplant, recipient and donor age and aetiology of heart failure were also compared with patients transplanted in the decades 1990-1999 and 2000-2009. METHODS: Our Heart Transplant Program Database and medical records of all cardiac transplants performed in our centre from July 1984 to 1989 were reviewed. Primary endpoint of the study was the long-term survival and secondary end points were the incidence of transplant-related complications over time. RESULTS: Forty-five transplants were performed in 1984-1989, 41 patients were male, median age was 46 years (IQR: 39-55), median donor age was 24 years (19-29) and mean graft ischemic time was 134±64 minutes. The actuarial survival of this cohort was 77.8%, 64.4%, 48.9%, 35.6% and 24.2% at 1, 5, 10, 15 and 20 years, respectively. Univariate Cox regression analysis revealed the female gender, the graft ischemic time, the recipient-donor gender mismatch, a diagnosis of diabetes and the number of acute rejection episodes during the first year post-transplant as significant risk factors adversely affecting long-term survival. Cardiac allograft vasculopathy is the main cause of death. The mean recipient and donor age and the graft ischemic time have progressively increased over time but survival has not changed. CONCLUSION: The long-term outcome of heart transplantation is noteworthy. The main limiting factor for survival is the allograft vasculopathy. Considering the tremendous advances in the immunosuppressive therapy and in the understanding of CAV pathophisyology, we can hope for even better results in the next years.

Úlcera penetrante de aorta ascendente en un paciente asintomático / Penetrating ascending aortic ulcer in an asymptomatic patient

La úlcera penetrante de aorta (UPA) es la ulceración de una placa aterosclerótica que afecta a la lámina elástica interna de la aorta, y que puede evolucionar hacia un hematoma de pared o una disección aórtica si se produce el paso de sangre hacia la capa media. A pesar de que se localiza más frecuentemente en la aorta descendente, puede presentar una alta mortalidad en caso de situarse en la aorta ascendente, donde la cirugía está indicada aunque el paciente se encuentre asintomático. Presentamos el caso de un paciente sin sintomatología con úlcera penetrante de aorta ascendente (UPAA) ascendente sometido a sustitución de aorta ascendente por una prótesis vascular(AU)

Penetrating aortic ulcer (PAU) has been defined as an atherosclerotic plaque ulceration that breaks the internal elastic lamina of the aorta, which may progress to a wall hematoma or aortic dissection incase of blood seeping into the middle layer. Although PAU is commonly located in the descending aorta, the involvement of the ascending aorta can be fatal. Therefore, surgery is indicated even in asymptomatic patients presenting an ascending PAU. We report on an asymptomatic patient with ascending PAU referred for replacement of the ascending aorta with a composite prosthetic graft(AU)

[Left atrial appendage as a source of stroke: to close (and how), or not to close (and why)]. / La orejuela izquierda como fuente de accidentes cerebrovasculares: cerrar (y cómo), o no cerrar (y por qué).

The left atrial appendage is considered the main source of emboli in strokes in patients with atrial fibrillation. Oral anticoagulant therapy significantly reduces the risk of cerebral embolic events compared to aspirin, but it is associated with bleeding complications, and is not always used. Closure of the left atrial appendage reduces the rate of thromboembolic events, and it is currently recommended in patients with atrial fibrillation submitted to mitral valve surgery. However, the formation of emboli in these patients may be due to other causes, as the role of the atrial appendage could be less important than is assumed. Moreover, not all patients are candidates for oral anticoagulation, and not all are kept in a proper therapeutic range, which could justify the formation of atrial thrombi. There are several methods for performing the closure of the appendage: direct suture in concomitant mitral surgery, epicardial exclusion by stapling or clips, or endovascular occlusion by percutaneous application. However, the results seem inconclusive with regards to their effectiveness for complete occlusion of the appendage, safety, and efficacy in preventing cerebral embolic events. To add to the confusion, some authors reveal no clear benefit in suture closure, and even describe an increased risk of thromboembolism. We present a review of left atrial appendage closure for the prevention of strokes, as well as the different procedures described above.

La orejuela izquierda como fuente de accidentes cerebrovasculares: cerrar (y cómo), o no cerrar (y por qué) / Left atrial appendage as a source of stroke: to close (and how), or not to close (and why)

La orejuela izquierda se considera la principal fuente de émbolos en los accidentes cerebrovasculares que se producen en pacientes con fibrilación auricular. El tratamiento con anticoagulantes orales reduce significativamente el riesgo de accidentes embólicos cerebrales en relación con la aspirina, pero se asocia a riesgo de complicaciones hemorrágicas, por lo que no siempre son utilizados. Se ha descrito que el cierre de la orejuela izquierda reduce la tasa de accidentes tromboembólicos y en la actualidad se recomienda en pacientes en fibrilación auricular sometidos a cirugía mitral, pero la formación de émbolos en estos pacientes puede deberse a otras causas, y la implicación de la orejuela podría ser menor de la que se presupone. Además, no todos los pacientes son candidatos para la anticoagulación oral, y no todos se mantienen en un rango terapéutico adecuado, lo que podría justificar la formación de trombos auriculares. Existen diversos métodos para el cierre de la orejuela: sutura directa, exclusión epicárdica mediante grapadora o clip, u oclusión mediante los recientes dispositivos endovasculares de aplicación percutánea. Pero, según la bibliografía, la efectividad de estos métodos para ocluir completamente la orejuela, así como su seguridad y eficacia para la prevención de accidentes embólicos cerebrales, pueden presentar resultados dispares. Para aumentar la controversia, algunos métodos de cierre con sutura no revelan un claro beneficio e, incluso, en algunos se describe un aumento del riesgo de tromboembolismo. Se presenta una revisión sobre la necesidad de cierre de la orejuela izquierda para la prevención de accidentes vasculares cerebrales, así como los diversos procedimientos descritos(AU)

Left atrial appendage is considered the main source of emboli in stroke for patients with atrial fibrillation. Oral anticoagulant therapy significantly reduces the risk of cerebral embolic events as compared with aspirin, but it is associated with bleeding complications, and it is not considered an standard of care. Closure of the left atrial appendage reduces the rate of thromboembolic events, and currently it is recommended in patients with atrial fibrillation submitted to mitral valve surgery. However the formation of emboli in those patients may be due to other causes and the roll of the atrial appendage currently has not very well defined. Moreover, neither all patients are candidates for oral anticoagulation, nor patients with oral anticoagulant maintain a adequate therapeutic range, which could be justify the formation of atrial thrombi. There are several methods to perform the closure of the appendage: endocavitary suture in concomitant mitral surgery, epicardial exclusion by stapling or clips, or endovascular occlusion by percutaneous devices. However the results seem inconclusive in regards of their effectiveness for complete occlusion of the appendage, safety, and efficacy to prevent cerebral embolic events. To increase the confusion, some authors reveal no clear benefit in suture closure, and even more others described an increased risk of thromboembolism. We present a review of the left atrial appendage closure for prevention of stroke and the different procedures as previously described(AU)

Can the opportunity of cardio-pulmonary bypass be useful in complex general thoracic surgery problems? A report of nine cases.

AIM: We report on nine highly selected patients in whom the resection of the tumor was only possible with cardiopulmonary bypass (CPB). METHODS: Between November 1996 and November 2009, nine patients with non-cardiac tumors underwent surgery under CPB. Indications were: infiltration of the pulmonary vein in the left atrium (four cases), one case where the tumor (a paraganglioma apparently located in the subcarinal space) was actually in the atrium wall, one mediastinal liposarcoma with massive infiltration of the pericardium and the main pulmonary artery, and three tracheal tumors (2 cylindromas and 1 carcinoid). RESULTS: Indication for CPB was decided preoperatively in 7 cases and intraoperatively in the other 2 patients. Cardiac infiltration was confirmed with intraoperative transesophageal cardiac echography in 2 patients, which proved to be very useful. Concerning postoperative complications, one patient died intraoperatively because it was impossible to stop the CPB after reconstruction of the bifurcation of the main pulmonary artery. Although the duration of the operation was significantly increased by the use of cardiopulmonary by-pass, it did not influence postoperative recovery in any of the other eight patients, as far as bleeding or infection was concerned. In one patient, a thoracic drain had to be replaced due to a partial pneumothorax. In another patient a partial dehiscence of the neo-carina was conservatively treated. Long-term results were influenced by the initial pathology of the patient. CONCLUSION: CPB provides the possibility of safely resecting intrathoracic tumors invading cardiac structures that were previously inoperable. This can be achieved with an acceptable level of risk and - in very selected cases - may achieve long-term survival.

Accuracy of different reconstruction intervals to quantify left ventricular function and mass in cardiac computed tomography examinations.

PURPOSE: To compare the accuracy of cardiac dual-source CT (DSCT) reconstructions obtained at 5% and 10% of the cardiac cycle and MRI for quantifying global left ventricular (LV) function and mass in heart transplant recipients. MATERIAL AND METHODS: We prospectively included 23 heart transplant recipients (21 male, mean age 60±11.7 years) who underwent cardiac DSCT and MRI examinations. We compared LV parameters on cardiac DSCT reconstructions obtained at 5% (0%-95%) and 10% (0%-90%) intervals of the cardiac cycle and on double-oblique short-axis MR images. We determined ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and myocardial mass using commercially available semiautomated segmentation analysis software for DSCT datasets and conventional manual contour tracing for MR studies. RESULTS: Using different reconstruction intervals to quantify LV parameters at DSCT resulted in non-significant differences (P>.05). Compared to MRI, DSCT slightly overestimated LV-EDV, ESV, and mass when both 5% (11.5±25.1ml, 6.8±10.9ml, and 28.3±21.6g, respectively) and 10% (mean difference 15.3±26.3ml, 7.4±11.5ml, and 29.3±18.7g, respectively) reconstruction intervals were used. DSCT and MRI estimates of EF and SV were not significantly different. CONCLUSION: In heart transplant recipients, DSCT allows reliable quantification of LV function and mass compared with MRI, even using 10% interval reconstructions.

Improvement in chronic renal failure after mycophenolate mofetil introduction and cyclosporine dose reduction: four-year results from a cohort of heart transplant recipients.

Chronic renal failure (CRF) due to calcineurin inhibitor (CNI) nephrotoxicity is a frequent complication among heart transplant (HT) recipients. Small studies have suggested that the introduction of mycophenolate mofetil (MMF) can help to reduce CNI doses thereby to maintaining or improving renal function. We conducted a 4-year, prospective, multicenter study in 89 maintenance HT recipients at 5.6 ± 2.7 years postgrafting who displayed CRF (serum creatinine > 1.4 mg/dL) and were undergoing treatment with cyclosporine and prednisone ± azathioprine. We introduced MMF and reduced cyclosporine to level below 100 ng/mL. Creatinine clearance (CrCl), acute rejection episodes, and survival were through retrospectively compared with a contemporary cohort of HT recipients who were not treated with MMF (control group; n = 38). After conversion to MMF, a rapid increase was observed in the CrCl, which was maintained over the follow-up: namely, CrCl at month 6 and at 4 years were 51.0 ± 15.6 and 54.1 ± 15.6 mL/min versus 41.9 ± 11.1 mL/min at baseline (P < .0001). No renal function changes were observed among the control group. Acute rejection rates were 5.6% and 2.6% in the MMF versus control groups (P = NS) with 4-year survivals >85%. In conclusion, the introduction of MMF allowed a safe reduction of cyclosporine and significantly improved renal function after 4 years.

[Atrial fibrillation surgery]. / Cirugía de la fibrilación auricular.

Atrial fibrillation surgery is based on creating scars in the atrium, in order to avoid re-entry phenomena that may initiate and perpetuate arrhythmia, and driving the normal stimuli from the sinus node to the atrio-ventricular node. The complexity and increased risk of the initial surgical technique, based on a "cut-and-sew" procedure, have enhanced other current procedures, in which different energies are used making it possible to perform scars in a safer and less invasive way. At present, atrial fibrillation surgery is not performed routinely in all cardiothoracic surgical centers, and there is no consensus in which is the best type of technique. Even if the results are good, they depend on multiples factors such as duration of arrhythmia, atrial size and type of technique employed. In addition, there is some variability in the description within the scientific community of the results and procedures used, which makes its analysis confusing. In this paper we review the different techniques described, the results and their application in minimally invasive surgery.

Lung cancer after heart transplantation: results from a large multicenter registry.

In this study we analyzed Spanish Post-Heart-Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post-HT follow-up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post-HT. Incidence increased with age at HT from 149 per 100 000 person-years among under-45s to 542 among over-64s; was 4.6 times greater among men than women; and was four times greater among pre-HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age-at-diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan-Meier 2-year survival to 70% versus 16% among inoperable patients.