Small cell lung cancer treatment and survival in Portugal: A retrospective analysis from the I-O Optimise initiative.

OBJECTIVE: We aim to describe treatment patterns and overall survival (OS) among a Portuguese cohort of patients with small cell lung cancer (SCLC). METHODS: This study utilised a database held by IPO-Porto, Portugal's largest oncology hospital. Adult patients diagnosed with SCLC at IPO-Porto between January 2012 and June 2017, with follow-up to December 2017, were included. Patients were stratified into subgroups with limited disease (LD) or extensive disease (ED). Treatment analyses were performed from 2015 onwards. RESULTS: Overall, 227 patients diagnosed with SCLC (37 LD; 190 ED) were analysed. Median OS (interquartile range [IQR]) was 15.0 months (3.8-39.3) for LD-SCLC and 5.0 months (1.7-10.3) for ED-SCLC. Among 19 patients diagnosed with LD-SCLC from 2015 onwards, 12 (63.2%) received initial treatment with systemic anticancer therapy (SACT) ± radiotherapy; 6 (31.6%) received best supportive care (BSC). Among 89 patients with ED-SCLC, 57 (68.5%) received SACT ± palliative radiotherapy; 28 (31.5%) received BSC. For patients receiving platinum doublet chemotherapy (±radiotherapy), median OS (IQR) was not reached for LD-SCLC and 5.4 months (2.3-10.9) for ED-SCLC. CONCLUSION: This real-world data analysis from a large Portuguese oncology hospital demonstrates a high disease burden for patients diagnosed with SCLC, particularly those with ED, and highlights a need for more effective therapies.

Treatment and outcomes for early non-small-cell lung cancer: a retrospective analysis of a Portuguese hospital database.

AIM: This observational study evaluated treatment patterns and survival for patients with stage I-IIIA non-small-cell lung cancer (NSCLC). MATERIALS & METHODS: Adults newly diagnosed with NSCLC in 2012-2016 at IPO-Porto hospital were included. Treatment data were available for patients diagnosed in 2015-2016. RESULTS: 495 patients were included (median age: 67 years). The most common treatments were surgery alone or with another therapy (stage I: 66%) and systemic anticancer therapy plus radiotherapy (stage II: 54%; stage IIIA: 59%). One-year OS (95% CI) for patients with stage I, II and IIIA NSCLC (diagnosed 2012-2016) were 92% (88-96), 71% (62-82) and 69% (63-75), respectively; one-year OS (95% CI) for treated patients with stage I-II or stage IIIA NSCLC (diagnosed 2015-2016) were 89% (81-97) and 86% (75-98) for non-squamous cell and 76% (60-95) and 49% (34-70) for squamous cell NSCLC. CONCLUSION: Treatment advances are strongly needed for stage I-IIIA NSCLC, especially for patients with squamous cell histology.

Holistic view of patients with melanoma of the skin: how can health systems create value and achieve better clinical outcomes?

Patients with skin cancer should be treated in healthcare units that ensure holistic and multidisciplinary approaches. Current healthcare units, especially those dedicated to cancer care, must evolve to integrated patient-centred systems. The current review presents a holistic health services perspective towards managing patients with melanoma of the skin, based on a literature search. It includes a detailed discussion on how this could impact on the patient, his or her quality of life and on service providers. Data from a multidisciplinary integrated practice unit, specialised in skin cancer, were also discussed, namely, for outcomes measurements, access to innovative treatments, value-based healthcare, patient centricity and use of integrated systems. Epidemiology data, including disease determinants and risk factors, play an important role in defining measures, resources and management of these integrated cancer units. To optimise effective care and improve survival outcomes, integrated cancer clinics should comprise, in a patient-centred way, innovative treatments and technologies, along with continuous training and creation of multidisciplinary units of healthcare professionals. Measurement of outcomes, such as clinical, quality of life and cost, is decisive in determining affordability and access to the best available state-of-the-art care. Besides, treatment of melanoma has significantly improved over recent years, but with increasing costs, which brings a challenging mission to guarantee access to treatment and quality care. Value-based healthcare allows the achievement of better health outcomes and higher quality services while reducing the costs associated with the full-care cycle. Therefore, current healthcare systems should develop in line with health institutions' organisation and culture, increasing adherence to best practices and create value.

The historical evolution of knowledge of the involvement of neurohormonal systems in the pathophysiology and treatment of heart failure. / A evolução histórica do envolvimento dos sistemas neuro­humorais no conhecimento da fisiopatologia e do tratamento da insuficiência cardíaca.

Our knowledge of the pathophysiology of heart failure (HF) underwent profound changes during the 1980s. Once thought to be of exclusively structural origin, HF began to be seen as the consequence of hormonal imbalance. A number of seminal studies were published in that decade focusing on the impact of neurohormonal activation in HF. Presently, eight neurohormonal systems are known to have a key role in HF development: four stimulate vasoconstriction and sodium/water retention (the sympathetic nervous system, the renin-angiotensin-aldosterone system [RAAS], endothelin, and the vasopressin-arginine system), while the other four stimulate vasodilation and natriuresis (the prostaglandin system, nitric oxide, the dopaminergic system, and the natriuretic peptide system [NPS]). These systems are strongly interconnected and are subject to intricate regulation, functioning together in a delicate homeostasis. Disruption of this homeostasis is characteristic of HF. This review explores the historical development of knowledge on the impact of the neurohormonal systems on HF pathophysiology, from the first studies to current understanding. In addition, the therapeutic potential of each of these systems is discussed, and currently used neurohormonal antagonists are characterized. Special emphasis is given to the latest drug approved for use in HF with reduced ejection fraction, sacubitril/valsartan. This drug combines two different molecules, acting on two different systems (RAAS and NPS) simultaneously.

Benchmarking Cancer Centers: From Care Pathways to Integrated Practice Units.

Background: Structuring cancer care into pathways can reduce variability in clinical practice and improve patient outcomes. International benchmarking can help centers with regard to development, implementation, and evaluation. A further step in the development of multidisciplinary care is to organize care in integrated practice units (IPUs), encompassing the whole pathway and relevant organizational aspects. However, research on this topic is limited. This article describes the development and results of a benchmark tool for cancer care pathways and explores IPU development in cancer centers. Methods: The benchmark tool was developed according to a 13-step benchmarking method and piloted in 7 European cancer centers. Centers provided data and site visits were performed to understand the context in which the cancer center operates and to clarify additional questions. Benchmark data were structured into pathway development and evaluation and assessed against key IPU features. Results: Benchmark results showed that most centers have formalized multidisciplinary pathways and that care teams differed in composition, and found almost 2-fold differences in mammography use efficiency. Suggestions for improvement included positioning pathways formally and structurally evaluating outcomes at a sufficiently high frequency. Based on the benchmark, 3 centers indicating that they had a breast cancer IPU were scored differently on implementation. Overall, we found that centers in Europe are in various stages of development of pathways and IPUs, ranging from an informal pathway structure to a full IPU-type of organization. Conclusions: A benchmark tool for care pathways was successfully developed and tested, and is available in an open format. Our tool allows for the assessment of pathway organization and can be used to assess the status of IPU development. Opportunities for improvement were identified regarding the organization of care pathways and the development toward IPUs. Three centers are in varying degrees of implementation and can be characterized as breast cancer IPUs. Organizing cancer care in an IPU could yield multiple performance improvements.

The cost of cancer treatment in Portugal.

INTRODUCTION: Cancer is the second most common cause of death in Portugal, with 24.3% of these deaths caused by malignant neoplasms. The strong impact on lost productivity and rising treatment costs make cancer a priority. In order to understand, compare, and control costs by promoting transparency in the health system, it is vital to analyse the cost of oncological diseases. This study aims to estimate the economic burden associated with the treatment of cancer in Portugal by calculating the direct medical costs. MATERIALS AND METHODS: A prevalence-based study was conducted. The approaches used to estimate the costs were the top-down and gross costing techniques. In order to identify, quantify, and value all of the costs associated with the treatment of cancer, several sources of data were consulted to obtain the most up-to-date information on hospital care and a modified Delphi Panel was created to obtain data on primary health care. RESULTS: The annual cost of cancer treatment in Portugal amounted to 867 million euros, representing 5.5% of the total expenditure for health and 84 euros per capita. The main component of this cost is antineoplastic drugs, which account for 31.5% of the total. DISCUSSION AND CONCLUSION: By comparing the costs calculated in this study with those of the single Portuguese study conducted in 2009 and the European study carried out in 2013, we found that the annual cost for cancer treatment increased by about 300 million euros. An increase in incidence and the rising cost of drugs can explain this difference.

Depression predicts mortality and hospitalization in heart failure: A six-years follow-up study.

BACKGROUND: The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF. METHODS: A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale-second edition (BDI-II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors. RESULTS: During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027). Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228-6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230-8.164; p=0.027). These associations were independent of conventional risk factors. LIMITATIONS: Only outpatient sample; measure of DS only at baseline; cause of death was not known. CONCLUSION: This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.

The Effect of Exercise Training on Diastolic and Systolic Function After Acute Myocardial Infarction: A Randomized Study.

After acute myocardial infarction (AMI), diastolic dysfunction is frequent and an important determinant of adverse outcome. However, few interventions have proven to be effective in improving diastolic function. We aimed to determine the effect of exercise training on diastolic and systolic function after AMI.One month after AMI, 188 patients were prospectively randomized (1:1) to an 8-week supervised program of endurance and resistance exercise training (n = 86; 55.9 ±â€Š10.8 years) versus standard of care (n = 89; 55.4 ±â€Š10.3 years). All patients were submitted to detailed echocardiography and cardiopulmonary exercise test, at baseline and immediately after the study. Diastolic function was evaluated by the determination of tissue-Doppler derived early diastolic velocities (E' velocity at the septal and lateral sides of mitral annulus) and by the E/E' (ratio between the E wave velocity from mitral inflow and the E' velocity) as recommended in the consensus document for diastolic function assessment.At the end of the study, there was no significant change in E' septal velocity or E/E' septal ratio in the exercise group. We observed a small, although nonsignificant, improvement in E' lateral (mean change 0.1 ±â€Š2.0 cm/s; P = 0.40) and E/E' lateral ratio (mean change of -0.3 ±â€Š2.5; P = 0.24), while patients in the control group had a nonsignificant reduction in E' lateral (mean change -0.4 ±â€Š1.9 cm/s; P = 0.09) and an increase in E/E' lateral ratio (mean change + 0.3 ±â€Š3.3; P = 0.34). No relevant changes occurred in other diastolic parameters. The exercise-training program also did not improve systolic function (either tissue Doppler systolic velocities or ejection fraction).Exercise capacity improved only in the exercise-training group, with an increase of 1.6 mL/kg/min in pVO2 (P = 0.001) and of 1.9 mL/kg/min in VO2 at anaerobic threshold (P < 0.001).After AMI, an 8-week endurance plus resistance exercise-training program did not significantly improve diastolic or systolic function, although it was associated with an improvement in exercise capacity parameters.

Health-related quality of life and utilities in gastric premalignant conditions and malignant lesions: a multicentre study in a high prevalence country.

BACKGROUND AND AIMS: A recent review of economic studies relating to gastric cancer revealed that authors use different tests to estimate utilities in patients with and without gastric cancer. Our aim was to determine the utilities of gastric premalignant conditions and adenocarcinoma with a single standardized health measure instrument. METHODS: Cross-sectional nationwide study of patients undergoing upper endoscopy (n=1,434) using the EQ-5D-5L quality of life (QoL) questionnaire. RESULTS: According to EQ-5D-5L, utilities in individuals without gastric lesions were 0.78 (95% confidence interval: 0.76-0.80), with gastric premalignant conditions 0.79 (0.77-0.81), previously treated for gastric cancer 0.77 (0.73-0.81) and with present cancer 0.68 (0.55-0.81). Self-reported QoL according to the visual analogue scale (VAS) for the same groups were 0.67 (0.66-0.69), 0.67 (0.66-0.69), 0.62 (0.59-0.65) and 0.62 (0.54-0.70) respectively. Utilities were consistently lower in women versus men (no lesions 0.71 vs. 0.78; premalignant conditions 0.70 vs. 0.82; treated for cancer 0.72 vs. 0.78 and present cancer 0.66 vs. 0.70). CONCLUSION: The health-related QoL utilities of patients with premalignant conditions are similar to those without gastric diseases whereas patients with present cancer show decreased utilities. Moreover, women had consistently lower utilities than men. These results confirm that the use of a single standardized instrument such as the EQ-5D-5L for all stages of the gastric carcinogenesis cascade is feasible and that it captures differences between conditions and gender dissimilarities, being relevant information for authors pretending to conduct further cost-utility analysis.

Comparative analysis and meta-analysis of major clinical trials with oral factor Xa inhibitors versus warfarin in atrial fibrillation.

OBJECTIVES: A comparative analysis of three major clinical trials with factor Xa inhibitor oral anticoagulant (XOAC) drugs versus warfarin in atrial fibrillation-Rocket-AF (rivaroxaban), Aristotle (apixaban) and Engage AF Timi 48 (edoxaban; two different doses and sets of data)-was carried out. METHODS: Data were extracted from the original reports (study level) and a meta-analysis was carried out. RESULTS: When compared with warfarin, XOAC therapy was associated with a decrease in haemorrhagic stroke, with a similar pattern for all regimens and meta-analysis showing a risk ratio of 0.488 (95% CI 0.396 to 0.601). Regarding total mortality, a favourable pattern was seen for all four regimens and meta-analysis showed a risk ratio of 0.892 (95% CI 0.840 to 0.947). Major bleeding and gastrointestinal bleeding provided two examples regarding which heterogeneity would seem to exist, when XOAC drugs are compared with warfarin. In what concerns the incidence of myocardial infarction, the primary end point (stroke plus systemic embolism) and ischaemic stroke, the situation is less clear. These results are inconsistent with a putative 'group effect' for all the seven parameters under study, and for some of them it would probably be best to look at each of the individual trial data rather than at the meta-analysis data (which seem to lack a clear biological meaning). CONCLUSIONS: Apixaban, rivaroxaban and edoxaban have shown interesting effects, when compared with warfarin in clinical trials, in patients with atrial fibrillation, particularly with regard to haemorrhagic stroke and to the mortality rate. No other consistent conclusions concerning a putative 'group effect' can be reached at the present stage. Concerns regarding adherence to therapy, possible drug interactions, cost and current absence of antidotes may be taken into consideration when choosing an anticoagulant drug.

Survival of patients with familial dilated cardiomyopathy on optimal heart failure therapy.

BACKGROUND: Familial dilated cardiomyopathy (FDCM) is characterized by clinical and genetic heterogeneity. There are still few survival studies concerning this subgroup of patients. AIM: To determine the prognosis of patients with FDCM on optimal medical therapy and attending a heart failure clinic. METHODS: This is a prospective study including patients with FDCM, defined according to the guidelines of the European Society of Cardiology. Cardiovascular morbidity and all-cause mortality were evaluated. RESULTS: Thirty-six patients, 23 (64%) men, were followed for 3.8 +/- 2.5 years. Age at baseline was 42 +/- 14 years and 67% were in NYHA class II. In 22% heart failure symptoms first occurred after a respiratory infection, and in 6%, after pregnancy/delivery. Most patients were in sinus rhythm (89%) and 33% had left bundle branch block (LBBB). Baseline left ventricular (LV) ejection fraction was 28 +/- 9%, LV end-diastolic diameter was 68 +/- 8 mm and left atrial dimension was 46 +/- 9 mm. Baseline serum sodium was 140 +/- 3 mEq/l. All patients were taking angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-II receptor blockers (ARBs), 81% beta-blockers and 47% spironolactone. During follow-up, 5 patients died, 4 underwent heart transplantation and one received an implantable cardioverter-defibrillator. Five-year survival was 68%. CONCLUSIONS: Five-year survival of our patients with FDCM, under optimal medical therapy, was similar to that of other forms of nonischemic DCM reported in the literature.

Effects of hypoglycemic agents on mortality and major cardiovascular outcomes in patients with type 2 diabetes mellitus: a narrative review [88].

Type 2 diabetes mellitus acts as a risk factor for cardiovascular disease. It has been hypothesized that control of plasma glucose levels would reduce cardiovascular disease in type 2 diabetic patients--thus lowering parameters such as mortality rate, myocardial infarction or stroke. A narrative review was carried out looking at data on mortality and cardiovascular disease outcomes, including myocardial infarction and stroke, associated with hypoglycemic therapy in type 2 diabetic patients, starting with the University Group Diabetes Trial (1970-1978) and ending with the Veterans Affairs Diabetes Trial (2009). The data reviewed in the present text fail to confirm the hypothesis presented above. No consistent relation between lowering plasma glucose and favorable effects either on mortality rate or on major cardiovascular disease has been clearly shown to exist. However, there are interesting data concerning drugs that lower plasma insulin levels, particularly metformin, but also, to a certain degree, pioglitazone. Also of interest are data on a possible legacy effect observed in the long-term follow-up of patients previously under intensive plasma glucose control. Consistent evidence in favor of lowering glycated hemoglobin levels to values under 7% also seems to be lacking at present, at least concerning mortality and cardiovascular outcomes. For the time being, it can be argued that efforts should be centered on interventions with clear evidence of benefit, such as treatment of hypertension or excessive weight, as well as the use of statins.

Glomerular filtration rate and coronary artery disease burden in patients with acute coronary syndrome.

BACKGROUND: Mild renal dysfunction may be associated with increased cardiovascular morbidity and mortality. METHODS: The relation between estimated glomerular filtration rate (eGFR), as calculated from plasma creatinine at admission, and coronary artery disease burden (CADB), was studied in a cohort of 110 patients with acute coronary syndrome and coronary atherosclerosis. RESULTS: A relatively weak but significant negative correlation was found between eGFR and CADB as measured by angiography (coefficient correlation of - 0.26, probability value of 0.006); a similar association was seen in multiple regression analysis, taking CADB as dependent variable, and eGFR, age, plasma calcium and plasma phosphorus as independent variables. After dividing the 110 patients into eGFR tertiles (with mean values of 102.9 +/- 22.8, n = 37, 75.7 + or - 5.6, n = 36, and 53.1 +/- 13.4, n = 37, all in mL/min per 1.73 m(2)), mean CADB values of the lower and higher eGFR tertiles were found to be significantly different (270.6 +/- 176.4 and 192.9 +/- 78.5, respectively). Similar mean values for CADB and for eGFR were noted when patients with elevated ST segment/new left bundle branch block and patients with nonelevated ST segment acute coronary syndrome were compared. CONCLUSIONS: We conclude that renal function of patients with acute coronary syndromes and coronary atherosclerosis, as estimated at admission, is negatively correlated with coronary artery disease burden. It is unknown whether renal dysfunction acts as a cause for accelerated coronary artery disease or if it merely acts as a surrogate marker for the overall systemic vascular system status.

Troponin I as a marker of right ventricular dysfunction and severity of pulmonary embolism.

BACKGROUND: Cardiac troponin I (cTnI) is a specific marker which allows detection of minor myocardial cell damage. In patients with severe pulmonary embolism (PE), the rise in pulmonary artery pressure can lead to progressive right ventricular dysfunction (RVD), and clinical studies have demonstrated the presence of ischemia and even right ventricular infarction. Our aims were to determine the prevalence and diagnostic utility of cTnI in identifying patients with RVD and to ascertain whether it correlates with severity of PE. METHODS: We studied 77 patients with PE diagnosed by pulmonary angiography, ventilation-perfusion lung scan, spiral computed tomography scan or a combination of abnormal echocardiogram with clinical presentation suggestive of PE or with positive subsidiary exams (d-dimers, venous Doppler of the lower limbs, ECG, blood gas analysis). We further classified the PE according to the European Society of Cardiology severity levels, the PE being: 1) massive, if there was shock and/or hypotension; 2) submassive, if we found right ventricular hypokinesis on the echocardiogram; and 3) non-massive, in the remaining cases. We considered the highest cTnI serum value from the admission to 24 hours and a normal value of < 0.10 ng/ml. RESULTS: Among the 60 patients with cTnI measurements, 42 had elevated values. Among those with RVD, 26 (81.3%) had increased cTnI levels and only 14 (35%) with elevated cTnI values did not have RVD, indicating that positive cTnI tests were significantly associated with RVD (p = 0.038). Patients with positive cTnI tests had earlier onset of symptoms (24.0 vs. 144.0 hours, p=0.02), higher prevalence of emboli in proximal vessels (pulmonary trunk and right or left main pulmonary arteries) (OR = 12, CI= 1.6-88.7), and received more thrombolytic therapy (OR = 5.4, CI = 1.1-26.8) than those with normal cTnI tests. cTnI levels were higher among patients with submassive PE (median: 0.77 ng/ml) and lower in those with non-massive PE (0.08 mg/ml, p < 0.05). CONCLUSIONS: Around 70% of patients with PE have elevated cTnI values and this test is significantly associated with RVD. cTnI measurements provide additional information in the evaluation of patients with PE by identifying more severe cases and those at increased risk of hemodynamic deterioration, who can benefit from more aggressive therapeutic strategies.

Tetralogy of Fallot: prognostic factors after surgical repair.

INTRODUCTION AND OBJECTIVE: Corrective surgery for tetralogy of Fallot (TF) has led to excellent survival. However; several years after surgery, the majority of patients have right ventricular (RV) dilatation, and 10% will need reoperation of the RV outflow tract due to limited exercise capacity, ventricular arrhythmias or symptoms of heart failure (HF). Our aim was to identify predictive factors of adverse outcome: moderate to severe RV dilatation, HF, reoperation of the RV outflow tract and cardiac death. METHODS: Eighty-eight adult patients with TF were operated between January 1977 and July 2001; 22 were lost to follow-up and 66 were followed for 18 +/- 6 years. We analyzed clinical, electrocardiographic and echocardiographic variables. RV dilatation was considered to exist if the inlet measurement at end-diastole in 4-chamber apical view was more than 35 mm, being classified as moderate when > or = 50 and < 60 mm and severe when > or = 60 mm. RESULTS: Of the 66 patients, 25 (37.9%) had undergone previous palliative shunt (PS) at the age of 4 +/- 5 years. Mean age at surgical correction was 10 +/- 8 years (range: < 1 to 38 years; median: 6.5 years). Transannular patching was used in 65% of patients, patch closure of a right ventriculotomy in 91%, and in 53% of patients a pulmonary commissurotomy was performed. At the end of follow-up, 3 patients were in NYHA class III-IV and one patient was successfully reoperated with implantation of a biological pulmonary valve. Prevalence of RV dilatation was 97% (57/59), being moderate to severe in 69% (36/52). In patients with moderate to severe RV dilatation we found previous PS (18.8 vs. 50.0%; p = 0.03), transannular patching (37.5 vs. 75.0%; p 0.01) and wide QRS (160 ms) (6.7 vs. 45.7%, p = 0.01) to be more frequent. These patients reported more palpitations (0 vs. 22.2%; p 0.05), but there were no differences in arrhythmic events (18.8 vs. 33.3%; p = 0.28); maximal heart rate on exercise was lower (86.2 +/- 10.9 vs. 79.9 +/- 8.6; p = 0.04), but exercise time and functional capacity were similar between the groups. Follow-up time and use of RV patching were similar. Transannular patching was associated with previous PS at an older age (0.9 +/- 0.7 vs. 4.9 +/- 5.7 years; p = 0.01), a higher grade of pulmonary regurgitation (III-IV) (22.7 vs. 57.5%; p = 0.01), wide QRS (160 ms) (9.5 vs. 41.0%, p = 0.01), and greater RV dilatation. No mortality was reported. CONCLUSION: Transannular patching and performance of previous PS were predictive factors of severe RV dilatation, and pulmonary regurgitation seems to be its physiological mechanism. Despite this, long-term prognosis is favorable and patients have good functional capacity.

Heart transplantation. A Portuguese hospital center's experience.

Cardiac transplantation is the gold standard therapy for patients below 60 years presenting with severe heart failure (HF) despite maximal medical therapy, who have no other surgical option and no contraindications to this procedure. We evaluated our experience with this important form of heart failure therapy. Between February 1987 and December 2002, 32 patients, aged 37 +/- 16 years, 19 males, with ejection fraction of 18 +/- 7%, underwent heart transplantation in our center. Seven (22%) patients were in NYHA class IV with hemodynamic support. Seventeen (53%) patients had idiopathic dilated cardiomyopathy (DCM), 7 (22%) had ischemic DCM, 3 (9%) had valvular DCM and the remainder had other causes of left ventricular dysfunction. Overall survival rate was 68% at first year post-transplantation, 59% at 5 years and 59% at 10 years. One year after cardiac transplantation, 95% of patients were in NYHA class I and the rest were in NYHA class II. Among the 13 patients who died, in five (18%) death occurred during the first month: the most frequent cause was hemodynamic failure. Causes of late death were: allograft vasculopathy (n = 3), allograft rejection (n = 1), infection (n = 1), sudden death (n = 1), hemodynamic failure (n = 1) and bradyarrhythmia (n = 1). Among the patients followed for more than one year, only three died. Early complications were: infection (8 episodes, 7 of respiratory location), right heart failure (3 patients), pericardial effusion (5 patients) and others (7 patients). Late complications were: a) allograft rejection: 17 (53%) patients, 72 episodes (10 ISHLT grade 3, 6 of whom were treated with intravenous corticotherapy, 8 grade 2 and 54 grade 1); b) infections: 19 (59%) patients; 35 episodes, 25 requiring hospitalization: 10 (28%) involving the respiratory tract, 6 (17%) the oropharynx, 5 (14%) the urinary tract, 4 (11%) the skin and 10 (28%) of undetermined location; c) chronic allograft rejection: 6 (19%) patients; d) arterial hypertension: 14 (45%) patients; d) renal failure: 5 (16%) patients; e) diabetes: 2 (6%) patients; f) cancer: 2 (6%) patients. Patients with severe heart failure and a very poor prognosis who underwent cardiac transplantation in our hospital showed marked improvement in functional capacity and quality of life and had an overall survival similar to the results of international heart transplantation registries. Complications during follow-up were similar to those usually described in the literature.