Impact of Circulatory Assistance in the Early Evolution After Heart Transplantation. Unicentric Experience.

BACKGROUND: Heart transplantation (HT) is the reference treatment for patients with terminal heart failure. In recent years there has been a progressive increase in HT procedures in patients who have a circulatory support (CS). METHODS: This is a retrospective single-center study of 293 consecutive patients who underwent HT from 2009 to 2018, analyzing the evolution of the 2 cohorts: patients with and without CS as a bridge to HT. Baseline and evolutionary clinical data collected following the usual follow-up protocol were recorded, including clinical events observed during the follow-up 1 year after the procedure. RESULTS: The subgroup of patients transplanted with CS showed a higher incidence of primary graft failure, frequent infection, and mortality. A tendency toward lower cardiac allograft vasculopathy was observed in this subgroup. Mechanical ventilation added to the CS resulted in a higher incidence of primary graft failure, infection, and renal dysfunction. The CS variable as a bridge to HT was shown to be predictive of 1-year mortality in both univariate (odds ratio, 1.84; 95% confidence interval, 1.03-3.3; P = .038) and multivariate (odds ratio, 2.1; 95% confidence interval, 1.01-4.3; P = .047) analyses. CONCLUSIONS: In our experience, CS as a bridge to HT results in a higher incidence of primary graft failure, frequent infection, and mortality at 1-year follow-up. Mechanical ventilation added to CS has a clear unfavorable prognostic impact. CS as a bridge to HT was shown to be predictive of 1-year mortality in both univariate and multivariate analyses.

Deregulated hepatic microRNAs underlie the association between non-alcoholic fatty liver disease and coronary artery disease.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) appears to be a new risk factor for the development of coronary artery disease (CAD). Members of a class of non-coding RNAs, termed microRNAs (miRNAs), have been identified as post-transcriptional regulators of cholesterol homoeostasis and can contribute to the development of NAFLD. The aims of this study were to (i) to assess the relationship between NAFLD and sudden cardiac death (SCD) from severe CAD in forensic autopsies and (ii) to quantify several hepatic miRNAs previously associated with lipid metabolism and NAFLD to correlate their expression with the presence of NAFLD, CAD, obesity parameters and postmortem lipid profile. METHODS: A total of 133 cases of autopsies with SCD and established CAD (patient group, CAD-SCD) and 106 cases of non-CAD sudden death (control group, non-CAD-SD) were included. miRNAs were quantified in frozen liver tissues. RESULTS: Males predominated in both groups. Patients more frequently exhibited NAFLD and necroinflammatory steatohepatitis (NASH) than controls (62% vs 26%, P = 0.001 and 42% vs 26%, P = 0.001 respectively). In both groups, the presence of NAFLD correlated with body mass index and abdominal circumference (P < 0.05). An increase in miR-34a-5p and a decrease in miR-122-5p and -29c-3p in patients with NASH vs controls without NAFLD were observed (P < 0.05). Finally, significant correlations between miR-122-5p and unfavourable lipid profile and also hs-CRP and miR-34a-5p were noted. CONCLUSIONS: CAD is associated with NAFLD and NASH. The hepatic miRNAs studied appear to be associated with NAFLD severity and may promote CAD through lipid metabolism alteration and/or promotion of the systemic inflammation.

Sensibilidad y valor predictivo negativo de la ergometría para el diagnóstico de la taquicardia ventricular polimórfica catecolaminérgica. Respuesta / Sensitivity and negative predictive value of treadmill exercise stress testing for the diagnosis of catecholaminergic polymorphic ventricular tachycardia. Response

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Valor del electrocardiograma como predictor de disfunción ventricular derecha en pacientes con sobrecarga crónica de volumen del ventrículo derecho / Value of the electrocardiogram as a predictor of right ventricular dysfunction in patients with chronic right ventricular volume overload

Introducción y objetivos: La insuficiencia pulmonar es una complicación frecuente en pacientes con tetralogía de Fallot o estenosis pulmonar congénita reparada. Se han correlacionado variables electrocardiográficas con parámetros de función del ventrículo derecho. Proponemos analizar el valor diagnóstico de la anchura y la fragmentación del electrocardiograma en la identificación de pacientes con disfunción y/o dilatación del ventrículo derecho. Métodos: Seleccionamos a 107 pacientes consecutivos diagnosticados de insuficiencia pulmonar grave tras reparación de estenosis pulmonar o tetralogía de Fallot. Se les realizó electrocardiograma, ecocardiograma y resonancia magnética. Cada electrocardiograma se analizó manualmente midiendo la duración del QRS. Definimos fragmentación del QRS como la presencia de ondas de bajo voltaje en la porción terminal del QRS en al menos dos derivaciones contiguas. Resultados: Se obtuvo una correlación negativa y significativa entre anchura del QRS y función del ventrículo derecho, así como una correlación positiva con el volumen de este. De la curva ROC se obtuvo el punto de corte en 140 ms de anchura del QRS, que mostró buena sensibilidad para el diagnóstico de dilatación (> 80%) y disfunción (> 95%) del ventrículo derecho. En los modelos de regresión logística, QRSd > 140 ms se mostró como el único predictor independiente de dilatación y disfunción del ventrículo derecho. Conclusiones: El electrocardiograma es una herramienta rápida, disponible y reproducible. La anchura del QRS permite predecir de manera independiente la presencia de dilatación y disfunción del ventrículo derecho. Este es el primer estudio que propone un punto de corte en la anchura del QRS para el cribado de afección del ventrículo derecho (AU)

Introduction and objectives. Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. Methods. We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. Results. We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140 ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140 ms was found to be the only independent predictor of right ventricular dilation and dysfunction. Conclusions. Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement (AU)

Value of the Electrocardiogram as a Predictor of Right Ventricular Dysfunction in Patients With Chronic Right Ventricular Volume Overload.

INTRODUCTION AND OBJECTIVES: Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. METHODS: We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. RESULTS: We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140ms was found to be the only independent predictor of right ventricular dilation and dysfunction. CONCLUSIONS: Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement.

Nuclear magnetic resonance imaging in patients with cardiac pacing devices.

Currently, nuclear magnetic resonance imaging is contraindicated in patients with a pacemaker or implantable cardioverter-defibrillator. This study was carried out because the potential risks in this situation need to be clearly defined. This prospective study evaluated clinical and electrical parameters before and after magnetic resonance imaging was performed in 33 patients (five with implantable cardioverter-defibrillators and 28 with pacemakers). In these patients, magnetic resonance imaging was considered clinically essential. There were no clinical complications. There was a temporary communication failure in two cases, sensing errors during imaging in two cases, and a safety signal was generated in one pacemaker at the maximum magnetic resonance frequency and output level. There were no technical restrictions on imaging nor were there any permanent changes in the performance of the cardiac pacing device.

Resonancia magnética nuclear en pacientes portadores de dispositivos de estimulación cardiaca / Nuclear magnetic resonance imaging in patients with cardiac pacing devices

La resonancia magnética está actualmente contraindicada a los pacientes portadores de dispositivos de estimulación cardiaca. Ante la necesidad de concretar los riesgos potenciales derivados de esta situación, surgió este estudio. De forma prospectiva, se evaluaron parámetros clínicos, eléctricos y técnicos antes y después de la realización de la prueba en 33 pacientes (5 desfibriladores automáticos implantables, 28 marcapasos), en los que se consideró clínicamente indispensable realizarla. No se apreciaron complicaciones clínicas. Se detectaron dos casos de fallo temporal de telemetría, dos errores de detección durante la exploración y una respuesta de seguridad en un marcapasos a frecuencia magnética y salida máxima. No hubo limitaciones técnicas en la adquisición de imágenes ni alteraciones permanentes del funcionamiento de los dispositivos de estimulación cardiaca (AU)

Currently, nuclear magnetic resonance imaging is contraindicated in patients with a pacemaker or implantable cardioverter-defibrillator. This study was carried out because the potential risks in this situation need to be clearly defined. This prospective study evaluated clinical and electrical parameters before and after magnetic resonance imaging was performed in 33 patients (five with implantable cardioverter-defibrillators and 28 with pacemakers). In these patients, magnetic resonance imaging was considered clinically essential. There were no clinical complications. There was a temporary communication failure in two cases, sensing errors during imaging in two cases, and a safety signal was generated in one pacemaker at the maximum magnetic resonance frequency and output level. There were no technical restrictions on imaging nor were there any permanent changes in the performance of the cardiac pacing device (AU)

[Impact of diabetes mellitus on heart transplant recipients]. / Impacto de la diabetes mellitus en el paciente con trasplante cardiaco.

INTRODUCTION AND OBJECTIVES: At present, there is some controversy about the impact of diabetes mellitus on heart transplant patients. The effect of the disease on mortality and on other complications, such as infection or rejection, is unclear. The objective of this study was to investigate these factors in our heart transplant patients. METHODS: We studied 365 consecutive patients who underwent heart transplantation between November 1987 and May 2003. We divided them in three groups according to whether they had pretransplantation diabetes (group 1), de novo diabetes (group 2), or no diabetes (group 3). Baseline variables and the development of complications were recorded, and findings were analyzed using Student's t test, chi squared test, and Kaplan-Meier survival analysis. RESULTS: There was no difference in the 1-year or 5-year survival rate between the groups (P=.24 and P=.32, respectively). Patients with pretransplantation and de novo diabetes were older (54.6 years vs 54.9 years vs 50.6 years, P=.04), had a higher prevalence of hypertension (48% vs 36% vs 23%, P=.001), and had more frequently been treated with tacrolimus (10% vs 12% vs 4%, P=.04) or steroids (92% vs 86% vs 70%, P=.001). The incidence of rejection during follow-up was greater in these two groups (64% vs 70% vs 45%, P=.001). CONCLUSIONS: Neither pretransplantation diabetes nor de novo diabetes had a negative impact on survival in our heart transplant patients. The disease's presence was associated with treatment with steroids and tacrolimus. In these patients it would be preferable to individualize immunosuppressive therapy.

Impacto de la diabetes mellitus en el paciente con trasplante cardiaco / Impact of diabetes mellitus on heart transplant recipients

Introducción y objetivos. Actualmente, el impacto de la diabetes mellitus en los pacientes con trasplante cardiaco es controvertido y su efecto sobre la mortalidad y otras complicaciones, como las infecciones y los rechazos, no está completamente aclarado. El objetivo de este estudio es analizar estos efectos en nuestra población de pacientes trasplantados. Métodos. Se ha estudiado a una población de 365 pacientes consecutivos con trasplante cardiaco desde noviembre de 1987 hasta mayo de 2003, dividiéndolos en 3 grupos en función de la presencia de diabetes pretrasplante (grupo 1), diabetes de novo (grupo 2) y no diabéticos (grupo 3). Se analizaron variables tanto basales como de complicaciones evolutivas, y los resultados se compararon mediante test t de Student, test χ² y método de Kaplan-Meier para la supervivencia. Resultados. No apreciamos diferencias entre grupos en la supervivencia al año (p = 0,24) ni a 5 años (p = 0,32). Los pacientes de los grupos con diabetes mellitus pretrasplante y de novo tenían mayor edad (54,6 frente a 54,9 frente a 50,6 años; p = 0,04), mayor prevalencia de hipertensión arterial (el 48, el 36 y el 23%; p = 0,001) y mayor porcentaje de tratamiento con tacrolimus (el 10, el 12 y el 4%; p = 0,04) y esteroides (el 92, el 86 y el 70%; p = 0,001). Evolutivamente, estos 2 grupos presentan mayor incidencia de rechazo (el 64, el 70 y el 45%; p = 0,001). Conclusiones. La diabetes previa al trasplante o de novo no tuvo impacto negativo sobre la supervivencia de nuestros pacientes trasplantados. Su presencia se asocia al tratamiento con esteroides y tacrolimus. En estos pacientes sería deseable realizar un ajuste individualizado de la inmunodepresión

Introduction and objectives. At present, there is some controversy about the impact of diabetes mellitus on heart transplant patients. The effect of the disease on mortality and on other complications, such as infection or rejection, is unclear. The objective of this study was to investigate these factors in our heart transplant patients. Methods. We studied 365 consecutive patients who underwent heart transplantation between November 1987 and May 2003. We divided them in three groups according to whether they had pretransplantation diabetes (group 1), de novo diabetes (group 2), or no diabetes (group 3). Baseline variables and the development of complications were recorded, and findings were analyzed using Student's t test, chi squared test, and Kaplan-Meier survival analysis. Results. There was no difference in the 1-year or 5-year survival rate between the groups (P=.24 and P=.32, respectively). Patients with pretransplantation and de novo diabetes were older (54.6 years vs 54.9 years vs 50.6 years, P=.04), had a higher prevalence of hypertension (48% vs 36% vs 23%, P=.001), and had more frequently been treated with tacrolimus (10% vs 12% vs 4%, P=.04) or steroids (92% vs 86% vs 70%, P=.001). The incidence of rejection during follow-up was greater in these two groups (64% vs 70% vs 45%, P=.001). Conclusions. Neither pretransplantation diabetes nor de novo diabetes had a negative impact on survival in our heart transplant patients. The disease's presence was associated with treatment with steroids and tacrolimus. In these patients it would be preferable to individualize immunosuppressive therapy

Síndrome takotsubo con lesiones coronarias acompañantes / Takotsubo syndrome with coronary lesions

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Lipoprotein (a) in young individuals as a marker of the presence of ischemic heart disease and the severity of coronary lesions.

The purpose of this study was to evaluate whether high levels and small isoforms of lipoprotein (a) [Lp(a)] are markers of risk of early myocardial infarction and markers of the severity of coronary atherosclerosis. Lp(a) levels and small apo(a) isoforms were higher in 222 patients than in 199 controls (p<0.001). In patients, Lp(a)> or =30 mg/dL was associated with the presence of coronary lesions (p=0.007) and the severity of coronary atherosclerosis (p=0.002). The present study suggests that Lp(a) levels and small isoforms are markers of early myocardial infarction and that Lp(a) levels > or =30 mg/dL are associated with severe patterns of coronary atherosclerosis.

The presence of epsilon waves in a patient with acute right ventricular infarction.

Epsilon wave is an unusual electrocardiographical finding, which may appear in other pathological conditions besides the arrhythmogenic right ventricular dysplasia, particularly in the acute myocardial infarction of the right ventricle, the inferior, or the posterior wall of the left ventricle. Its real incidence in these acute coronary syndromes remains unknown and will be probably difficult to assert, since it may be unnoticed by inexperienced physicians because of its little voltage. The outstanding interest of this case lies in the clear electrocardiographical images and in the step-by-step differential diagnosis discussed by the authors.

Ventricular natriuretic peptide (BNP) in heart transplantation: BNP correlation with endomyocardial biopsy, laboratory and hemodynamic measures.

A prospective study of 81 heart transplant (HT) patients was carried out in order to evaluate the evolution of brain natriuretic peptide (BNP) levels in HT patients and compare them with the degree of rejection as determined by endomyocardial biopsy. All patients were subjected to endomyocardial biopsy (532), and determination of BNP and creatinine levels as well as hemodynamic parameters. A control group of 36 volunteers was included. BNP values were significantly greater in HT patients than in healthy volunteers. In the first 3 months, BNP levels in patients with treatable rejection were significantly greater than in patients without graft rejection, although evident overlapping was observed in both distributions and discriminatory potential was low. After the third month, BNP values were similar in patients with and without rejection. Creatinine levels were observed to increase over time after transplantation, but no correlation was observed between the creatinine and BNP levels. A significant positive correlation was observed between BNP and right ventricle and pulmonary arterial pressures.

[Analysis of factors that can influence the appearance of acute heart transplant failure]. / Análisis de los factores que pueden influir en la aparición del fallo agudo del corazón trasplantado.

INTRODUCTION AND OBJECTIVE: Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF. MATERIAL AND METHOD: In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model. RESULTS: The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01). CONCLUSIONS: AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

[Usefulness of the electrocardiogram in predicting the occlusion site in acute anterior myocardial infarction with isolated disease of the left anterior descending coronary artery]. / Utilidad del electrocardiograma para predecir el lugar de la oclusión en el infarto agudo de miocardio anterior con enfermedad aislada de la arteria descendente anterior.

INTRODUCTION AND OBJECTIVES: In acute anterior myocardial infarction (AMI), the site of occlusion in the left anterior descending coronary artery (LAD) is related to the extension of myocardial necrosis and the prognosis. The aim of this study was to assess the value of the electrocardiogram (ECG) as a predictor of the LAD occlusion site in patients with anterior AMI. METHODS: Forty-five consecutive patients with a first anterior AMI and isolated disease of the LAD were included. We evaluated retrospectively the ECG with the most pronounced ST-segment changes before fibrinolysis and correlated the findings with the site of LAD occlusion in angiography before hospital discharge in relation to the first dominant septal and first diagonal branch: first septal affected (S), first diagonal affected (D), both affected (S + D), or neither affected were considered. RESULTS: ST depression in leads II, III, or aVF strongly predicted proximal LAD occlusion in S + D, S, and D (p = 0,003, p = 0,04, and p = 0,02, respectively). ST elevation in leads II, III, or aVF was observed only in the presence of wrap-around LAD and was related with occlusion distal to the first diagonal branch. ST elevation > or = 3 mm in lead V1 was a specific predictor of occlusion proximal to first septal (S, p = 0,01). ST elevation in aVR was associated with proximal LAD occlusion in S + D and S (p = 0,03 and p = 0,03, respectively) and absence of coronary collateral circulation. CONCLUSIONS: In anterior AMI and isolated LAD disease, the ECG can be useful in predicting the LAD occlusion site in relation to its major side branches.

[Brain natriuretic peptide. Diagnostic value in heart failure]. / Péptido cerebral natriurético. Valor diagnóstico en la insuficiencia cardíaca.

BACKGROUND: Nowadays a number of diverse biochemical markers have been identified in patients with heart failure (HF) that could indicate the severity of the patients' illness. Among them, probably the most useful is brain natriuretic peptide (BNP) because it is easily obtained and because of its diagnostic and prognostic information. Our objective was to assess the association between BNP and other different associated variables previously known to be related to the evolution of HF, as well as its utility to distinguish systolic from diastolic HF. PATIENTS AND METHOD: We studied 114 patients admitted consecutively for symptomatic HF for all causes (age: 66 years, male: 60%). In all patients plasma BNP was measured, from the third day of admission, with a specific radioinmunoassay. Echocardiography was performed in 101 patients. RESULTS: BNP plasma levels increased in proportion to functional class (p = 0.01) and the degree of left ventricular dysfunction (p = 0.0001, r = 0.44). There was also an association between BNP and male sex (p = 0.008), higher plasmatic creatinine (p = 0.01, r = 0.25), Iarger ventricular diameters (p = 0.0001) and higher pulmonary systolic pressure (p = 0.001, r = 0.44). In the multivariate analysis, BNP was independently related to the rest of variables with left systolic ventricular function (p = 0.0001). Despite this association, we did not find a satisfactory cut-off value in BNP, with a good sensitivity and specificity value from the total number of patients, of which specifically systolic dysfunction as a cause of HF was detected. CONCLUSIONS: a) BNP increases proportionately to the left ventricular dysfunction and HF severity, and b) BNP is not a useful tool to distinguish systolic from diastolic HF.