Idarucizumab in High-risk Thoracic Surgery.

Direct oral anticoagulants have suggested a favorable profile compared with vitamin K antagonists. However, the lack of treatment to reverse the effect of direct oral anticoagulants has limited its use in some patients who require rapid reversal of anticoagulation, as those included in the transplant waiting list. Idarucizumab is a recently approved drug to reverse the anticoagulant effect of dabigatran. However, the clinical experience when using this drug is scarce. Herein, we present a clinical case on anticoagulation reversal with idarucizumab to perform heart and lung transplantation in a patient with Eisenmenger syndrome.

Noninvasive Liver Assessment in Adult Patients With Fontan Circulation Using Acoustic Radiation Force Impulse Elastography and Hepatic Magnetic Resonance Imaging.

BACKGROUND: Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). METHODS: In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. RESULTS: Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. CONCLUSIONS: There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.

High-Bandpass Filters in Electrocardiography: Source of Error in the Interpretation of the ST Segment.

Introduction. Artifactual variations in the ST segment may lead to confusion with acute coronary syndromes. Objective. To evaluate how the technical characteristics of the recording mode may distort the ST segment. Material and Method. We made a series of electrocardiograms using different filter configurations in 45 asymptomatic patients. A spectral analysis of the electrocardiograms was made by discrete Fourier transforms, and an accurate recomposition of the ECG signal was obtained from the addition of successive harmonics. Digital high-pass filters of 0.05 and 0.5 Hz were used, and the resulting shapes were compared with the originals. Results. In 42 patients (93%) clinically significant alterations in ST segment level were detected. These changes were only seen in "real time mode" with high-pass filter of 0.5 Hz. Conclusions. Interpretation of the ST segment in "real time mode" should only be carried out using high-pass filters of 0.05 Hz.

Effect of circulatory assistance on premature death and long-term prognosis.

BACKGROUND: Patients undergoing urgent heart transplantation (HT) have a poorer prognosis and more long-term complications. The objective of this study was to compare the preoperative course in patients undergoing urgent HT according to the need for preoperative intra-aortic balloon counterpulsation (IABP). MATERIALS AND METHODS: We studied 102 consecutive patients including 23 patients with IABP who underwent urgent HT between January 2000 and September 2006. We excluded patients who received combination transplants, those who underwent repeat HT, and pediatric patients who underwent HT. The statistical methods used were the t test for quantitative variables and the chi(2) test for qualitative variables. A logistic regression model was constructed to assess the possible relationship between IABP and other variables on premature death within 30 days after HT. RESULTS: Mean (SD) patient-age was 50 (10) years. No significant differences were observed in baseline characteristics between the IABP and the non-IAPB groups. The IABP patient group had higher rates of acute graft failure (45.5% vs 35.4%; P = .46) and premature death (18.8% vs 14.8%; P = .67) and shorter long-term survival (40.6 [34.9] vs 54.5 [43.7] mo; P = .30). Multivariate analysis demonstrated no association between the need for IABP and increased frequency of premature death. CONCLUSIONS: Use of IABP is not associated with premature or late death. We recommend use of IABP in patients with acute decompensated heart failure to stabilize them before HT.

Effect of hypertension, diabetes, and smoking on development of renal dysfunction after heart transplantation.

BACKGROUND: Renal dysfunction is a serious problem after heart transplantation (HT). The objective of this study was to determine the cardiovascular risk factors associated with medium- to long-term dysfunction after HT. MATERIALS AND METHODS: We studied 247 consecutive patients who underwent HT between January 2000 and September 2006 who survived for at least 6 months. We excluded patients receiving combination transplants, those undergoing repeat HT, and pediatric patients undergoing HT. Mean (SD) follow-up was 72 (42) months. We defined renal dysfunction as serum creatinine concentration greater than 1.4 mg/dL during follow-up. Patients were considered to be smokers if they had smoked during the six months before HT, to have hypertension if they required drugs for blood pressure control, and to have diabetes if they required insulin therapy. Statistical tests included the t test and the chi(2) tests. We performed Cox regression analysis using significant or nearly significant values in the univariate analysis. RESULTS: Mean (SD) age of the patients who underwent HT was 52 (10) years, and 217 (87.9%) were men. Renal dysfunction was detected during follow-up in 135 (54.5%) patients. The significant variables at univariate analysis were smoking (61.4% vs. 43.2%; P = .01) and previous renal dysfunction (94.1% vs 52.7%; P = .001). Nearly significant variables were the presence of hypertension before HT (63.8% vs 51.1%; P = .09) and after HT (58.2% vs 44.8%; P = .082). At multivariate analysis, pre-HT smoking and previous renal dysfunction were significant correlates (P = .04 and P = .01, respectively). CONCLUSIONS: Renal dysfunction is common after HT. In our analysis, the best predictors were pre-HT dysfunction and smoking. Less important factors were advanced age and post-HT hypertension.

Torsade de Pointes en un paciente con infección por el virus de la inmunodeficiencia humana y tratamiento con metadona / Torsade de Pointes in patient infected with human inmunodeficiency virus and treated with methadone

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[Utility of pravastin in cardiac transplant dyslipidemia]. / Utilidad de la pravastina en la dislipidemia del trasplante cardíaco.

Patients undergoing cardiac transplantation are at increased risk of dyslipidemia (60% to 80%). Lipid-lowering treatment in these patients should be aggressive given the known role of dyslipidemia in chronic transplant rejection. The objective of this study was to evaluate the efficacy and safety of pravastatina therapy and its effect upon cyclosporine levels in a population of dyslipidemic cardiac transplant patients.A total of 20 cardiac transplant patients were enrolled in this 39-week length prospective observational study. Patients had serum cholesterol levels exceeding 200 mg/dl, and received pravastatin therapy at the adequate dose to obtain an optimal lipid profile without significant adverse effects. Pravastatin, at a mean dose of 50 18 mg/day, produced a significant reduction in total cholesterol levels (from 291 32 to 203 25 mg/dl, p < 0.05), LDL cholesterol (from 187 34 to 102 15 mg/dl, p < 0.05) and an increase in HDL-cholesterol levels (from 48 16 to 55 14, p < 0.05). A slight asymptomatic increase in CPK levels was observed but no differences in cyclosporine levels. Pravastatin has shown to be an effective and safe therapy in dyslipidemic cardiac transplant patients.

Utilidad de la pravastina en la dislipidemia del trasplante cardíaco / Utility of pravastin in cardiac transplant dyslipidemia

Los pacientes sometidos a trasplante cardíaco tienen un mayor riesgo de dislipidemia (60 por ciento-80 por ciento).Debido al conocido papel de la dislipidemia en el desarrollo de enfermedad vascular del injerto, el tratamiento hipolipidemiante debería ser especialmente agresivo en estos pacientes. El objetivo de este estudio ha sido evaluar la eficacia y seguridad del tratamiento con pravastatina y su efecto sobre los niveles de ciclosporina sobre una población de pacientes trasplantados dislipidémicos.Incluimos, en este estudio prospectivo observacional de 39 semanas de duración, a 20 pacientes trasplantados cardíacos con cifras de colesterol basales por encima de 200 mg/dl, que recibieron tratamiento con pravastatina a la dosis necesaria para alcanzar un óptimo perfil lipídico o aparición de efectos adversos significativos. Pravastatina, a una dosis media de 50 ñ 18 mg/día, produjo una reducción significativa de los niveles de colesterol (de 291 ñ 32 a 203 ñ 25 mg/dl, p < 0,05), colesterol LDL (de 187 ñ 34 a 102 ñ 15 mg/dl, p < 0,05) e incrementó el colesterol HDL (de 48 ñ 16 a 55 ñ 14, p < 0,05).Observamos un ligero incremento de las cifras de creatinfosfocinasa (CPK) asintomático y sin mayor relevancia clínica, y los niveles de ciclosporina no experimentaron diferencias significativas.La pravastatina se ha mostrado en nuestro estudio como un tratamiento seguro y eficaz en pacientes trasplantados cardíacos con dislipidemia (AU)

¿Posee el fosinopril efecto reductor de los lípidos en los pacientes hipertensos? / Does fosinopril have the lipid lowering effect among hypertensive patients?

Objetivo. El propósito de este estudio fue analizar el efecto del fosinopril sobre la presión arterial, perfil lipídico, función renal, hepática y masa ventricular en pacientes con hipertensión ligera o moderada. Material y método. Se incluyeron 24 pacientes de 66ñ8 años, 14 mujeres y 10 varones, 16 con hipertensión arterial aislada y 8 asociada a cardiopatía isquémica. Medicación concomitante: aspirina 9; nitratos 8; bloqueadores beta 5; antidiabéticos orales 4; hipolipidemiantes 4; calcioantagonistas 3; diuréticos 3 y ranitidina 2 pacientes. Esta medicación no se modificó a lo largo del estudio. Se incluyeron pacientes consecutivos y estables diagnosticados de hipertensión arterial esencial. Se realizaron controles a la semana de retirar la medicación antihipertensiva (revisión 1), semanas 4 (revisión 2), 12 (revisión 3) y tras 7 días de retirar el fosinopril (revisión 4).Resultados. Hubo diferencias significativas (p<0,05) en la presión arterial sistólica y diastólica al comparar el valor basal (PAS: 159ñ11 mmHg; PAD: 99ñ8 mmHg) y a las 4 (PAS: 137ñ10 mmHg; PAD: 82ñ7 mmHg) y 12 semanas (PAS: 136ñ12; PAD: 85ñ8, incluso tras retirar el fármaco (PAS: 151ñ12 mmHg; PAD: 96ñ10 mmHg). No hubo cambios en los triglicéridos, colesterol total ni colesterol HDL. Tampoco en los parámetros de función hepática y renal. Se encontró un descenso significativo en el colesterol LDL a las 12 semanas (132ñ9 frente a 141ñ12) y tras la suspensión del fármaco (133ñ12 frente a 141ñ12). La Lp(a) mostró cambios significativos, con respecto al basal, en todas las revisiones (revisión 2: 5ñ22 frente a 8ñ23; revisión 3: 4ñ22 frente a 8ñ23) aunque experimentó un efecto rebote al retirar el fosinopril (10ñ21 frente a 8ñ23). No se apreciaron cambios en los parámetros de función diastólica ni en la fracción de eyección; no obstante, la masa ventricular sí experimentó un descenso significativo 253ñ58 frente a 276ñ59). Conclusiones. Según estos resultados, creemos que el fosinopril debe ser considerado un fármaco de primera línea en el tratamiento de la hipertensión arterial. Es capaz, por un lado, de reducir la masa ventricular y, por otro, de mejorar de forma significativa el perfil lipídico del paciente sin producir alteraciones en la función hepática o renal (AU)

[Emergency implantation of intracoronary stent after acute occlusion of the common trunk of the left coronary artery]. / Implantación emergente de stent intracoronario tras oclusión aguda del tronco común de la coronaria izquierda.

Nowadays, the implantation of coronary endoprosthesis within the left main coronary artery is not considered as an absolute contraindication. Here, we show a case of acute occlusion within the left main coronary artery. This was resolved by implanting a stent during a programmed cardiac catheterization. It should be stressed that this problem was occurred without manipulating the left coronary tree. In addition, the patient was in cardiac arrest when the stent was implanted. Cardiopulmonary resuscitation was applied because of this condition.