Combination therapy with sildenafil and bosentan reverts severe pulmonary hypertension and allows heart transplantation: case report.

INTRODUCTION: Severe pulmonary hypertension with no response to vasodilators on an acute hemodynamic study is a contraindication to cardiac transplantation. The development of oral pulmonary vasodilators improves the prognosis in these patients. We present the case of a patient whose admission to the waiting list for cardiac transplantation was possible after 6 months of combination therapy with Sildenafil and Bosentan. CASE REPORT: The patient was a 50-year-old man with severe dilated alcohol-induced cardiomyopathy. A pretransplantation study, including a right hemodynamic analysis, revealed irreversible pulmonary hypertension, with 59 mm Hg mean pulmonary artery pressure and 6.4 Wood IU pulmonary vascular resistance, with no response to acute vasodilators with nitric oxide or prostacyclin. Initially, heart transplantation was not possible and the patient started treatment with oral Sildenafil. After 6 months there was no improvement in echocardiographic or hemodynamic parameters, and combination therapy with Bosentan was started. With the combination therapy, the patient progressively improved clinically and hemodynamically, the pressures becoming normal at the sixth month, at which time he was included on the waiting list for a heart transplantation. Eight months later he received a graft with a good posttransplantation course, no right ventricular failure in the acute phase, and absence of pulmonary hypertension on echocardiogrphic and invasive studies. CONCLUSION: Combinations of an oral pulmonary vasodilator with diverse action mechanisms may represent an alternative for patients with irreversible pulmonary hypertension who do not respond to monotherapy.

Sirolimus experience in heart transplantation.

INTRODUCTION: Sirolimus is a potent, nonnephrotoxic immunosuppressant with antiproliferative activity in nonimmune cells. Recent data support the conversion in late renal failure secondary to calcineurin inhibitors (CNIs), with limited experience in de novo regimens in patients with predictive factors of postoperative renal impairment. OBJECTIVE: We evaluated our experience of sirolimus-based immunosuppression administered to 25 heart transplant recipients. METHODS: A retrospective analysis of 25 heart transplant recipients who received sirolimus included 17 conversions due to late CNI-related chronic renal dysfunction, six patients with a de novo regimen, and two patients who developed posttransplant pulmonary neoplasms. The conversion from CNI to sirolimus was started with 2 mg, with an average time after transplantation of 78 +/- 43 months and a mean baseline serum creatinine level of 2.1 +/- 0.45 mg/dL. The mean clinical follow-up was 17 +/- 9 months postconversion, and included echocardiography and laboratory studies. In the de novo group successive endomyocardial biopsies were performed during the first semester. RESULTS: Serum creatinine fell from 2.1 +/- 0.45 mg/dL to 1.8 +/- 0.51 mg/dL (P = .012). Mean sirolimus levels were 15 +/- 9 ng/mL (doses 2.2 +/- 0.4 mg). This improvement continued until 3 months (creatinine 1.5 +/- 0.35 P < .01)/sirolimus levels 11.7 +/- 5 ng/mL [1.9 +/- 0.7 mg]), with maintenance at 6 months (1.58 +/- 0.3 mg/dL/14 +/- 4 ng/mL [1.85 +/- 0.7 mg]) and 1-year postconversion (1.53 +/- 0.39 mg/dL; P = .019/10.7 +/- 2.5 ng/mL [1.5 +/- 0.7 mg]). De novo, after a mean follow-up of 13 months (range 3 to 35), sirolimus appeared to increase the incidence of a moderate histological grade of rejection without hemodynamic compromise. Side effects were common (63%), including peripheral edema, skin eruptions, and pericardial effusion. Only one patient discontinued treatment, due to intestinal intolerance. Four patients died during follow-up: two because of lung neoplasms and two because of progressive graft vessel disease. CONCLUSION: Sirolimus improved late CNI-related chronic renal dysfunction. Kidney function was preserved using a de novo CNI-free immunosuppressive regimen for recent cardiac transplant recipients.

Ventricular mass and diastolic function in patients infected by the human immunodeficiency virus.

OBJECTIVE: Echocardiographic and Doppler analysis of myocardial mass and diastolic function in patients infected with HIV. DESIGN: Case-control study. SETTING: Tertiary referral centre, Huelva, Spain. PATIENTS: 61 asymptomatic patients with HIV infection and 32 healthy controls. MAIN OUTCOME MEASURES: Time motion, cross sectional, and Doppler echocardiographic studies were performed, and left ventricular mass and diastolic function variables determined (peak velocity of early and late mitral outflow and isovolumic relaxation time). RESULTS: Left ventricular mass index (LVMI) was decreased in patients compared with healthy controls (mean (SD): 76.7 (23.6) v 118.8 (23.5) g/m(2), p < 0.001). Linear regression analysis showed a correlation between LVMI and brachial fat and muscle areas. The ratio of peak velocities of early and late mitral outflow was decreased in HIV infected patients compared with controls (1.19 (0.44) v 1.58 (0.38), p < 0.001). This ratio was exclusively related to haemodynamic variables (heart rate, systolic and diastolic blood pressures). HIV infected patients had a prolonged isovolumic relaxation time (103.0 (10.5) v 72.9 (12.9) ms, p < 0.001). Isovolumic relaxation time was correlated only with brachial muscle area on multivariate analysis. CONCLUSIONS: HIV infected patients had a reduced left ventricular mass index and diastolic functional abnormalities. These cardiac abnormalities are predominantly related to nutritional status.

[Prolonged asystole requiring resuscitation techniques during head-tilt table test]. / Asistolia prolongada que requiere maniobras de resucitación durante un test de basculación.

We describe a case of a patient with recurrent syncope without cardiac disease and with a normal electrophysiological study. The patient underwent a head-up tilt table test as a diagnostic method. During the test the individual suffered a twenty-nine seconds cardiac asystole. He recovered the cardiac rhythm nineteen seconds after having adopted the supine position and with resuscitation maneuvers. In the consulted bibliography, there is no evidence of such a long asystole induced during a head-up tilt table test, where the patient required a chest thumping. Commonly the spontaneous recuperation of the cardiac rhythm takes place immediately after the patient adopts a horizontal position. This case supports the hypothesis that the asystole provoked by a cardioinhibitor reflex in patients suffering from a vasovagal syncope, can become potentially lethal and therefore lead to sudden cardiac death.

Heart transplantation in a patient with liver hydatidosis.

The human can serve as an accidental intermediate host to Echinococcus granulosus, a parasite that targets dogs as its definitive hosts. We present the case of a 27-year-old man with liver hydatidosis, who underwent heart transplantation because of ischemic cardiomyopathy. The immunosuppressor treatment had no effect on the size of the cysts, which were removed surgically 14 months after heart transplantation; good results persist after 3 years of follow-up.

Massive ingestion of isosorbide-5-mononitrate and nitroglycerin: suicide attempt by an adolescent girl without previous heart disease.

High plasma levels of isosorbide-5-mononitrate were found in a young girl who had ingested 1.6 g of the drug plus 20 mg of nitroglycerin. These concentrations produced no disturbance of the patient's state of consciousness and no serious haemodynamic effects appeared except for a tachycardia in relation to peripheral vasodilatation.