Predicting Short- and Long-Term Outcomes in Adult Heart Transplantation: Clinical Utility of MELD-XI Score.

BACKGROUND: Model for End-Stage Liver Disease scoring system excluding international normalized ratio (MELD-XI) has been related with worse outcomes after heart transplantation (HT). However, according to standards in prognostic models research, before implementing a risk score for daily clinical decision-making, its performance and impact on clinical practice/outcomes should be evaluated. The aim of this study was to evaluate the ability of the MELD-XI score to predict outcomes in daily clinical practice. MATERIAL AND METHODS: We retrospectively reviewed 190 consecutive adults undergoing HT between 2005-2015. Patients were stratified into low (MELD-XI <12) and high (MELD-XI ≥12) risk cohorts. Mortality rates at 30 days and 1 year were compared between MELD-XI groups. MELD-XI ability to predict 1-year mortality was assessed by the area under the receiver operating curve (AUC) and compared to that of bilirubin, creatinine, and pulmonary vascular resistance (PVR). RESULTS: Mortality rates at 30 days and 1 year were similar between groups (8% vs 13%; P = .28 and 21% vs 29%; P = .21, respectively). MELD-XI ability to predict 1-year mortality was poor and similar to that of bilirubin, creatinine, and PVR (0.51 vs 0.47 vs 0.50 vs 0.50, respectively). CONCLUSIONS: MELD-XI score utility in HT clinical decision-making is scarce since its discrimination ability is poor and similar to other simple prognostic variables.

Manejo de los pacientes con fibrilación auricular en los servicios de urgencias hospitalarios (actualización 2012) / Atrial fibrillation management in the hospital emergency department: 2012 update

La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SHU), que presentan una frecuentación elevada y creciente en España. La FA es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento recoge las recomendaciones para el manejo de la FA, basadas en la evidencia disponible, y adaptadas a las especiales circunstancias de los SUH. En él se analizan con detalle las estrategias de tromboprofilaxis, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados (AU)

Atrial fibrillation is the most frecuently sustained arrhythmia managed in emergency departments, and accounts for a high and increasing prevalence in Spain. Atrial fibrillation is increases mortality, is associated with substantial complications and, therefore, has a relevant impact in running of the health care system. Management requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans that coordinate the work of medical staff in the interest of providing appropriate care and optimizing resources. These evidence-based guidelines contain recommendations for managing atrial fibrillation in the special circumstances of hospital emergency departments. Stroke prohylaxis, rate control, rhtyhm control, and related diagnostic and logistic issues are discussed in detail (AU)

Guías para el manejo de la fibrilación auricular en los servicios de urgencias hospitalarios / Guidelines for the managment of atrial fibrillation in hospital emergency services

No disponible

[Endocardial ablation of substrate of postinfarction ventricular tachycardia during sinus rhythm]. / Ablación endocárdica del sustrato de taquicardia ventricular postinfarto durante ritmo sinusal.

OBJECTIVE: Radiofrequency ablation of ventricular tachycardia requires good tachycardia tolerance during mapping and entrainment, and this limits its application. We present our initial experience with ventricular tachycardia ablation during sinus rhythm in 7 patients with previous inferior myocardial infarction. METHODS: Seven men, 56-70 years old (mean +/- SD, 65 +/- 4.5) were included in the study. Ventricular tachycardia was unstable in 6 and in 1 it was induced non-sustained. The scar was localized by recording low-voltage, fragmented electrograms (< 2 mV). Ventricular tachycardia "exit" was localized by pace-mapping in sinus rhythm. Radiofrequency lines were made radially, point by point, from normal to scarred tissue. One of the lines crossed the exit area. The objective was to achieve non-inducibility. RESULTS: Sustained clinical ventricular tachycardia was induced in 6 and non-sustained in 1. Two-four lines were performed per patient with 11-28 (21 +/- 5.4) radio frequency applications. The procedure duration was of 130-280 min (230 +/- 61) and being 49-75 min (63 +/- 7.9) for fluoroscopy. There were no complications. Clinical ventricular tachycardia became non-inducible in 6, although in 4 a rapid (cycle < or = 250 ms), non-clinical ventricular tachycardia remained inducible. Defibrillators were implanted in the patient remaining inducible for clinical ventricular tachycardia and another with > 60 tachycardia episodes the previous week. During 3-22 months (13.8 +/- 5.9) of follow-up, 1 patient died of heart failure at 20 months and another received 3 defibrillator shocks for VT at 13 months. There were no other episodes of ventricular tachycardia, syncope or sudden death. CONCLUSIONS: This preliminary experience suggests that radiofrequency ablation of post-infarction ventricular tachycardia substrate is possible during sinus rhythm, suggesting that radiofrequency ablation may be applicable in a large proportion of patients with post-infarction sustained ventricular tachycardia.

[Catheter ablation of atrial flutter and fibrillation]. / Ablación con catéter del flutter y la fibrilación auricular.

The knowledge of the anatomic and functional bases of common flutter circuits has allowed the definition of an anatomic isthmus, between the inferior vena cava and the tricuspid valve, where radiofrequency application can interrupt the circuit. Some atypical flutter circuits are identical to common flutter circuits, but for an inverted rotation (clockwise), and these can be also ablated in the same isthmus. In cases of flutter (or reentrant tachycardia) due to surgical scars in the atrium, mapping supported with programmed stimulation, can define anatomic isthmuses, where ablation can also interrupt the circuit. There is still no definition of left atrial flutter circuits, that may guide ablation in these cases. Atrial fibrillation ablation is still in its infancy. Some initial experiences have tried to reproduce the division of atrial myocardium as in the maze procedure, and fibrillation was interrupted in a number of patients, submitted to very long procedures. There is still no clear definition of the muscular anatomy of the left atrium, in relation with the fibrillatory process, to guide the design of effective ablation lines. There are also technical problems to produce continuous, transmural ablation lines, that are not arrhythmogenic by themselves. The wide clinical application of ablation to treat atrial fibrillation is still in the distant future.

[The curative treatment of incessant atrioventricular tachycardia by radiofrequency ablation]. / Curación de la taquicardia incesante auriculoventricular mediante ablación con radiofrecuencia.

The permanent form of junctional reciprocating tachycardia is due to accessory pathways with retrograde long conduction times. We report the localization of the atrial insertion of the accessory pathway and successful ablation with radiofrequency in 3 patients. The participation of an accessory pathway in the tachycardia was demonstrated by atrial capture without changes in the sequence, with ventricular stimuli during His bundle refractoriness. The atrial insertion was localized by mapping near the os of the coronary sinus. In all cases one to three radiofrequency pulses applied at this point interrupted the tachycardia. Retrograde conduction through the accessory pathway reappeared in 30 min or earlier in all, with displacement of the point of earliest atrial activation, and tachycardia recurred. Total abolition of accessory pathway conduction and cure of the tachycardia required new radiofrequency applications, that in one case were done in a second procedure.