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.

Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia / Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning

Objetivo: La membrana de oxigenación extracorpórea (ECMO) es un tipo de asistencia circulatoria que asocia elevada mortalidad. Sin embargo, superar la fase inicial de soporte mecánico no implica supervivencia ni a corto ni a largo plazo. Objetivo: describir las características y evolución de los pacientes con shock cardiogénico refractario (SCR) asistidos con ECMO veno-arterial (ECMO-VA) en un hospital con programa de trasplante cardíaco. Diseño: Estudio de cohortes y retrospectivo de centro único. Ámbito: UCI cardiológica de un hospital terciario. Pacientes: Un total de 46 pacientes asistidos consecutivamente con una ECMO-VA durante 6 años. Intervenciones: Análisis de la mortalidad hospitalaria tras la retirada del soporte mecánico, de la supervivencia global (SG) y de los factores asociados. Resultados: Quince pacientes (33%) fallecieron con la ECMO-VA y 31 (67%) sobrevivieron a su retirada tras un soporte de 8 días (RIC: 5-15); 14 pacientes fueron trasplantados. La mortalidad hospitalaria en estos pacientes fue del 32% (10/31) y se relacionó con: edad (p=0,001), SAPS-II (p=0,009), sangrado de cánulas (p=0,01), indicación de SCR post-IAM (p=0,001). Con una mediana de seguimiento de 27 meses (RIC: 11-49), seguían vivos el 91% de los pacientes que fueron dados de alta del hospital. La SG tras la retirada de la ECMO-VA se relacionó con el tipo de indicación (p=0,002), teniendo peor pronóstico los pacientes con SCR postinfarto. Conclusiones: En nuestra experiencia, la ECMO-VA es un tipo de asistencia mecánica que puede utilizarse en el manejo del SCR. Asocia una mortalidad precoz elevada, pero tras superar la fase hospitalaria la supervivencia de los pacientes es buena (AU)

Objective: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. Design: A single-center, retrospective cohort study was carried out. Setting: The cardiovascular ICU of a tertiary hospital. Patients: Forty-six patients consecutively subjected to VA-ECMO over 6 years. Interventions: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. Results: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. Conclusions: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good (AU)

Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning. / Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. DESIGN: A single-center, retrospective cohort study was carried out. SETTING: The cardiovascular ICU of a tertiary hospital. PATIENTS: Forty-six patients consecutively subjected to VA-ECMO over 6 years. INTERVENTIONS: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. RESULTS: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. CONCLUSIONS: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.

Alternativas al trasplante cardíaco / Alternatives to heart transplantation

La incidencia y prevalencia de la insuficiencia cardíaca congestiva en fase terminal en la población mayor de 65 años es creciente y requiere un manejo terapéutico especifico. El trasplante cardíaco es una opción sólo para un reducido número, ya que la disponibilidad de donantes es limitada y la presencia de criterios de exclusión (patología vascular periférica severa, diabetes mellitus mal controlada...) es frecuente en esta población. Recientemente se han desarrollando nuevos tratamientos: 1) Resincronización cardíaca 2) Asistencia ventricular 3) Plasmaferesis e inmunoabsorción 4) Tratamiento quirúrgico. Estas modalidades terapéuticas están en fase de desarrollo, con resultados iniciales prometedores, pero la experiencia acumulada es pequeña y limitada, y no se dispone de datos fiables que valoren eficacia a medio-largo plazo. (AU)

[Incidence and dynamic behavior of spontaneous echocardiographic contrast and atrial thrombi in the transplanted heart]. / Incidencia y comportamiento dinámico del contraste ecocardiográfico espontáneo y del trombo auricular en el corazón trasplantado.

BACKGROUND: Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations with subsequent thrombotic risk. Therefore the aim of this study was to analyze the prevalence and evolution of spontaneous echocardiography, atrial thrombi and embolic events. PATIENTS AND METHOD: 52 consecutive transplanted patients were analyzed with transesophageal echocardiography and hemodynamic studies performed at 15 days and one year after transplantation. RESULTS: Spontaneous echocardiography contrast was present in 27 patients (52%). Ten atrial thrombi were observed (19.2%), 9 with spontaneous echocardiography contrast. Six atrial thrombi appeared on day 15 and 4 after one year (with spontaneous echocardiography contrast on the previous study). Using multiple logistic regression analysis left atrial size was the only independent predictor factor for spontaneous echocardiography contrast (OR = 1.27; 95% CI, 1.09-1.54) and was an important predictor factor of atrial thrombi formation (OR = 1.19; 95% CI, 1.04-1.42). Likewise, the main predictor of atrial thrombi was the presence of spontaneous echocardiography contrast (OR = 116; 95% CI, 8.4-999). The hemodynamic pattern did not predict either the presence of spontaneous echocardiography contrast or atrial thrombi. The global incidence of embolic events was 4% less than previously described. CONCLUSIONS: The incidence of atrial thrombi and spontaneous echocardiographic contrast after standard orthotopic heart transplantation was 19.2% and 52%, respectively. An enlarged atrium and/or spontaneous echocardiography contrast was found to increase the risk of atrial thrombi. Considering the dynamic nature of atrial thrombi formation, periodical transesophageal echocardiography studies are recommended after heart transplantation.

[Early results with partial left ventriculectomy (the Batista operation)]. / Resultados precoces de la ventriculectomía parcial izquierda (operación de Batista).

INTRODUCTION AND OBJECTIVES: The shortage of donors as well as the morbidity and mortality associated with transplantation have led to development of other surgical options for end-stage dilated cardiomyopathy. Partial left ventriculectomy reducing ventricular diameter and mass has been proposed. We here in report the initial experience (not only limited to the alternative of transplantation) and immediate results obtained with this technique in our institution. METHODS: Six patients with dilated cardiomyopathy underwent surgery: 4 of idiopathic origin with exclusion criteria for heart transplantation and 2 of valvular or mixed etiology. Resection of a slice of the left ventricle was performed between the two papillary muscles, from the apex of the heart to the mitral annulus, and closure was carried out with a single suture with mitral annuloplasty in 5 cases (tricuspid repair in one and aortic valve replacement in two). RESULTS: An intraaortic balloon pump was required in two patients; one died from cardiogenic shock and the other died after several ventricular arrhythmias fifteen days after surgery. Intraoperative echocardiographic studies showed a significant reduction in both diastolic diameter (8.7 to 6.8 cm; p = 0.02) and mitral insufficiency and an increase in the ejection fraction (17 to 27%; p = 0.09) which were maintained on echography 10 days after surgery. CONCLUSIONS: This technique is a feasible, suitable therapeutic option for refractory congestive heart failure. Appropriate patient selection, the perioperative management and long-term support remain to be defined.

A new approach to cardiac valve replacement through a small midline incision and inverted L shape partial sternotomy.

OBJECTIVE: Minimally invasive cardiac surgery is becoming more popular as an alternative technique in some cardiac operations. We report our experience with an inverted 'L' ministernotomy in 25 patients and describe the technical details of this new approach. METHODS: From June 1996 to February 1997 we performed 25 ministernotomy approaches for cardiac surgery, 17 aortic and 7 mitral valve replacements and 1 atrial septal defect closure. A comparison group included all patients (n = 126) operated on for mitral or aortic valve replacement through a median sternotomy since June 1996. RESULTS: Ventilatory support, Intensive Care Unit stay and hospital stay were 8.3 h (SD = 4 h), 25 h (SD = 8 h) and 5.5 days (SD = 3 days) in the L ministernotomy group and 11.5 h (SD = 5), 53 h (SD = 11) and 9.1 days (SD = 4 days) in the median sternotomy group (P < 0 05). Mortality and morbidity are similar to conventional sternotomy (hospital mortality 4% vs. 5.5%; P not significant). CONCLUSIONS: We conclude that inverted L ministernotomy for cardiac surgery is a safe approach and can offer some advantages over the conventional approach.

[Scales of risk assessment in coronary surgery and their usefulness]. / Escalas de valoración de riesgo en cirugía coronaria y su utilidad.

Currently, there is an increasing interest in the fields of cardiology and cardiac surgery related to systems of risk assessment of cardiac surgery procedures. The main benefit of these systems is quality control of results obtained. Nevertheless, there are other interesting implications. Currently, most of the available scales make estimations of mortality risk with a defined operative technique, using preoperative variables. Other systems can make predictions on postoperative length of stay. Scales are built using the results of a large series, processed with different mathematical models. An important condition is the simplicity of use. There is a wide range of available systems originating from clinical experience in Europe and North-America. All of them include a common number of predictive factors, although the assigned weight can vary significantly. We recommend the routine use of these scales as a quality control system and as a method of characterization of our populations in order to make adequate comparisons among different groups.

Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis.

Mediastinitis after cardiac surgery is difficult to diagnose in many cases. The transitory epicardial pacing wires used after surgery are placed in the mediastinum, so the culture of these wires could be useful for the diagnosis of this disease. To test this hypothesis, we routinely cultured the epicardial pacing wires of 565 patients undergoing extracorporeal circulation. Wires were removed on the 7th to 9th postoperative day under sterile conditions and were cultured with routine techniques used for the culture of venous catheters. Mediastinitis developed in 16 patients, and Staphylococcus aureus was the most common pathogen (81.25%). We had 103 positive and 462 negative cultures. There were 458 true-negative, 12 true-positive, 91 false-positive and 4 false-negative results. For mediastinitis in general, epicardial pacing wire culture has a sensitivity of 75%, specificity of 83.4%, positive predictive value of 11.6%, and negative predictive value of 99.1%. For Staphylococcus aureus mediastinitis, epicardial pacing wire culture has a sensitivity of 84.6%, specificity of 95.8%, positive predictive value of 32.3%, and negative predictive value of 99.6%. We conclude that a sterile culture of the epicardial pacing wires strongly contradicts a diagnosis of postsurgical mediastinitis.

[Thromboendarterectomy as a treatment for chronic pulmonary hypertension]. / Tromboendarterectomía como tratamiento de la hipertensión pulmonar crónica.

Chronic pulmonary hypertension is an extremely difficult disease to diagnose and is usually identified by the exclusion of other more recognized causes of enlargement in mean pulmonary arterial resistance. Up to now, treatments proposed for this disease, have not been very successful. Medical procedures are not a long term proper solution which leads the process to an irreversible point whose only solution should be a pulmonary transplantation. In recent years, study groups have established a surgical method, alternative to transplantation, which has been able to increase, with a decrease in mortality rates, a longer and a better quality of life for the patients affected by this disease: we are talking about pulmonary thromboendarterectomy.

[Aortic valve replacement via ministernotomy]. / Sustitución valvular aórtica por miniesternotomía.

Minimally invasive cardiac surgery is arising as an alternative technique in some cardiac operations. We present the first aortic valve replacement via ministernotomy. We describe in detail the technique of ministernotomy and the limitations that this new approach would have. We conclude with the advantages of minimally invasive cardiac surgery over conventional approach and review other techniques described in the literature.

[Extracorporeal circulation in pregnancy: report of a case. Update and review of the literature]. / Circulación extracorpórea durante el embarazo: a propósito de un caso. Actualización y revisión de la literatura.

Parameters of flow, temperature and perfusion, and modifications in body fluids secondary to surgery with extracorporeal circulation do not imply an increase in maternal risk during pregnancy but they eventually considerably increase fetal morbimortality. We present the case of a 22 week pregnant woman with severe aortic stenosis who underwent extracorporeal surgery for valve replacement without fetal mortality during the procedure. Literature about the use of extracorporeal surgery in the treatment of valve pathology in pregnancy, the parameters in which the reduction of fetal morbimortality is based and alternative treatments are broadly reviewed.

[A method for the predictive estimation of the surgical risk in adult cardiac pathology]. / Método de estimación predictiva de riesgo quirúrgico en patología cardíaca de adultos.

INTRODUCTION: In order to test the efficiency of statistical predictive models, we compare the results of a standard method (Parsonnet) with the model created through the data of our population. MATERIAL AND METHODS: We used the chi 2 univariate model, lineal and logistic regression with the data of the whole population receiving cardiac surgical procedure from January 1, 1990 to December 31, 1993 (total 1626 patients). The population was divided into a control group (1100 cases, 68%) and a study group (526 cases, 32%). The coefficients of the control group were used to estimate the results in the study group. RESULTS: Univariate model p value. Significant (p < 0.001) for emergency, age, pulmonary hypertension, left ventricular failure, preoperative use of intra-aortic balloon pump; p < 0.05 mitral valve disease, aortic aneurysm and reoperation. No significance (p < 0.01) was found for gender, aortic or tricuspid disease, percutaneous transluminal coronary angioplasty, unstable or postinfarction angina, transplant, left main or vessel disease number, and mitral, tricuspid or aortic procedure. MULTIVARIATE MODEL: Emergency, pulmonary hypertension, age, left ventricular dysfunction and aortic aneurysm. We estimated a 5.2%, 5.2% and 11.4% mortality with linear, logistic and Parsonnet method respectively with a real group mortality of 6.5%. The average error of the observed and predicted mortality after risk stratification was 5.7%, 6% and 12%. CONCLUSION: A model for risk prediction based on the data of the own institution is more accurate for that population than a model created for comparison between institutions, because the former takes account of the center and population peculiarities.

[The emergency heart transplant]. / Trasplante cardíaco de urgencia.

From the International Registry on Cardiac Transplantation we can not infer a higher mortality in urgent or emergent Cardiac Transplantation. The data in the Spanish Registry and in the literature show that the risk is higher in these patients compared to non urgent transplantation, implying ethical considerations which are discussed in the article. A different approach to urgent transplantation could be based on previous circulatory support, or heart assist systems as a bridge to transplantation.