Prognostic indices in heart transplant candidates after the first hospitalization triggered by the need for intravenous pharmacologic circulatory support.

BACKGROUND: Patients with heart failure refractory to optimal oral pharmacologic therapy have a dismal short term prognosis. Heart transplantation is the only therapy shown to improve survival in these patients. Unfortunately, due to the critical shortage of donor organs, approximately 30% of listed patients with end-stage heart failure die before a suitable donor heart becomes available. The principal aim of this study was to determine whether intravenous pharmacologic circulatory support favorably influences the clinical course of heart transplant candidates or whether mechanical circulatory support should be instituted in this high risk patient population. METHODS: Data from 154 consecutive hospitalizations in 125 patients 49+/-12 years were retrospectively reviewed. The product limit method was used to estimate survival. Multiple logistic regression analysis was used to identify the clinical and hemodynamic variables that independently predict outcome after each admission in which heart transplantation did not occur. RESULTS: One year survival for the study population was 65%. This survival is significantly lower than the 91% 1 year survival in similarly ill patients undergoing heart transplantation. The Cox proportional hazard method identified serum bilirubin, blood urea nitrogen (BUN), serum sodium levels and right atrial pressure as independent prognostic indices. Serum bilirubin, BUN levels and duration of intravenous pharmacologic circulatory support were associated with a poor outcome. A composite index including serum bilirubin and BUN levels predicted outcome with a sensitivity and specificity of 79% and 77%, respectively. The addition of pharmacologic support duration increased the model's sensitivity to 95%, but did not significantly alter specificity that was 74%. Of the 125 patients hospitalized due to the need to initiate intravenous pharmacologic support for the first time (index hospitalization), 69 (55%) were discharged after optimization of medical therapy. Of 21 patients who did not undergo transplantation during the follow-up period, 18 (86%) died within 2 years of the index hospitalization. The duration of intravenous pharmacologic support beyond which prognosis dramatically worsens without heart transplantation is 21 days. CONCLUSION: Heart transplant candidates who require intravenous pharmacologic circulatory support for more than 21 days and do not receive a suitable donor heart within this period of time have a high mortality. Alternative therapies, such as implantation of a mechanical circulatory assist device should be considered in this high risk population.

[Inferior infarct with associated anterior ST elevation: an unusual presentation of right ventricular involvement. Description of three cases and a brief review of the problem]. / Infarto inferiore con sopraslivellamento del tratto ST anteriore associato: una presentazione inusuale del coinvolgimento del ventricolo destro. Descrizione di tre casi e breve revisione del problema.

ST segment elevation in the left precordial leads in the setting of an acute inferior myocardial infarction may represent an unusual electrocardiographic pattern of right ventricular infarction. We present our experience about three patients with first inferior acute myocardial infarction in whom concomitant anterior ST segment elevation was observed. All patients were submitted to urgent coronary angiography because of repeated episodes of myocardial ischemia (case 1) or hemodynamic derangement (case 2, 3) with hypokinetic arrhythmias (case 3). In all patients 2D echocardiographic examination performed before angiography showed a dilated, hypo-akinetic right ventricle and wall motion abnormalities only in inferior, posterior and/or lateral segments of the left ventricle. Proximal right coronary occlusion was found in all patients, and coronary angioplasty was successfully attempted in all but one case. In patients with first inferior myocardial infarction, left precordial ST segment elevation mimicking an anterior infarction may be the less frequent ECG pattern of right ventricle ischemic involvement. Routine right chest leads and early echocardiographic examination allow to identify the patients with right ventricle infarction and concomitant anterior ST segment elevation. In these patients, early and correct diagnosis is important in order to choice the appropriate therapeutic pathway.