Progresión y predictores de insuficiencia valvular neoaórtica y dilatación de la raíz neoaórtica en adultos jóvenes tras cirugía de switch arterial / Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation

Introducción y objetivos Hay pocos datos sobre la evolución en adultos de la dilatación de la raíz neoaórtica (RAO) y la insuficiencia valvular neoaórtica (IA) tras la cirugía de switch arterial (SA) en la transposición de grandes arterias. Métodos Análisis retrospectivo de 152 pacientes con transposición de grandes arterias, mayores de 15 años, intervenidos mediante SA y seguidos durante 4,9±3,3 años en 2 centros de referencia. Se analizaron los cambios de diámetro de la RAO ajustados a superficie corporal y la progresión a grado moderado/grave de la IA con ecocardiografías seriadas. Se realizó un modelo de regresión de Cox para identificar factores predictores de progresión de la IA. Resultados Inicialmente, 4 pacientes (2,6%) presentaban IA grave (3 habían precisado cirugía valvular) y 9 (5,9%) moderada. La RAO basal media era 20,05±2,4mm/m2, y al final del seguimiento, 20,73±2,8mm/m2 (p<0,001), con un crecimiento medio de 0,14 (IC95%, 0,07-0,2) mm/m2/año. La IA progresó en 20 (13,5%) y 6 (4%) fueron intervenidos. La progresión de IA se asoció con válvula bicúspide, IA inicial, dilatación de la RAO inicial y crecimiento de la RAO. La válvula bicúspide (HR=3,3; IC95%, 1,1-15,2; p=0,037), la IA inicial (HR=5,9; IC95%, 1,6-59,2; p=0,006) y el crecimiento de la RAO (HR=4,1; IC95%, 2-13,5; p=0,023) resultaron predictores independientes. Conclusiones La dilatación de la RAO y la IA progresan en el adulto joven intervenido mediante SA. La válvula bicúspide, la IA basal y el crecimiento de la RAO son predictores de progresión de IA. (AU)

Introduction and objectives There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life. Methods We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9±3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression. Results At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05±2.4mm/m2, which increased significantly to 20.73±2.8mm/m2 (P <.001) at the end of follow-up. The mean change over time was 0.14mm/m2/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P=.037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P=.006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P=.023). Conclusions In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD. (AU)

Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation.

INTRODUCTION AND OBJECTIVES: There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life. METHODS: We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9±3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression. RESULTS: At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05±2.4mm/m2, which increased significantly to 20.73±2.8mm/m2 (P <.001) at the end of follow-up. The mean change over time was 0.14mm/m2/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P=.037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P=.006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P=.023). CONCLUSIONS: In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD.

Are there differences in acute phase inflammation markers regarding the type of heart failure?

This study aimed to determine if there are differences in inflammatory markers in the acute phase between systolic heart failure and heart failure with preserved systolic function. One hundred and thirty-one patients with acute heart failure were recruited consecutively. At admission, plasma fibrinogen, C-reactive protein, sialic acid, von Willebrand factor, vascular endothelial growth factor, interleukin-6 and NTproBNP were all evaluated. If the ejection fraction was 45% or over patients were included in the HF-PSF group; the remaining patients were included in the SHF group. The HF-PSF patients were older (72±10 vs 63±12 years, P<0.001), presented a higher rate of atrial fibrillation (56.1 vs 21.3%, P<0.001), and had a lower rate of hemoglobin (12.2±2 vs 13.3±2.1 g/dL, P<0.01). No significant differences were observed in the inflammation markers analyzed among SHF and HF-PSF groups. In the acute phase of heart failure there is a marked elevation of inflammatory markers but there are no differences in the inflammatory markers analyzed between the two different types of heart failure.

Dosis repetidas de daclizumab para retrasar la instauración del inhibidor de la calcineurina en pacientes con trasplante cardiaco y disfunción renal postoperatoria / Repeated Daclizumab administration to delay the introduction of calcineurin inhibitors in heart transplant patients with postoperative renal dysfunction

El daclizumab es un antagonista del receptor de la IL-2 usado como terapia de inducción en el trasplante cardiaco con pocos efectos secundarios y baja tasa de infecciones. La insuficiencia renal postoperatoria tras un trasplante cardiaco es frecuente y potencialmente grave. La introducción de los inhibidores de la calcineurina en el postoperatorio puede agravar esta situación. Presentamos 6 casos de pacientes sometidos a trasplante cardiaco y que desarrollaron insuficiencia renal postoperatoria. En todos ellos se administró daclizumab de forma semanal para evitar la introducción del inhibidor de la calcineurina y permitir la recuperación renal. Una vez mejorada la función renal, se introdujo el inhibidor de la calcineurina. En todos los casos se recuperó la función renal y la tasa de complicaciones fue baja. La administración de dosis repetidas de daclizumab en pacientes con insuficiencia renal tras un trasplante cardiaco puede ser una alternativa para evitar el uso de inhibidores de la calcineurina y permitir así la recuperación de la función renal(AU)

Daclizumab is an interleukin-2 receptor antagonist which is used for induction therapy in heart transplant patients. It has few side effects and is associated with a low infection rate. Postoperative renal failure after heart transplantation is common and potentially fatal. The administration of calcineurin inhibitors in the postoperative period can aggravate the situation. We report the cases of six patients who underwent heart transplantation and developed acute renal failure in the immediate postoperative period. All were administered daclizumab weekly to avoid the introduction of calcineurin inhibitors and to facilitate recovery of renal function. Calcineurin inhibitors were introduced only once renal function had improved. Renal function recovered in all cases and there was a low complication rate. The administration of repeated doses of daclizumab to patients who experience acute postoperative renal failure after heart transplantation may provide an alternative therapeutic approach that enables calcineurin inhibitors to be avoided and, consequently, renal function to recover(AU)

Repeated daclizumab administration to delay the introduction of calcineurin inhibitors in heart transplant patients with postoperative renal dysfunction.

Daclizumab is an interleukin-2 receptor antagonist which is used for induction therapy in heart transplant patients. It has few side effects and is associated with a low infection rate. Postoperative renal failure after heart transplantation is common and potentially fatal. The administration of calcineurin inhibitors in the postoperative period can aggravate the situation. We report the cases of six patients who underwent heart transplantation and developed acute renal failure in the immediate postoperative period. All were administered daclizumab weekly to avoid the introduction of calcineurin inhibitors and to facilitate recovery of renal function. Calcineurin inhibitors were introduced only once renal function had improved. Renal function recovered in all cases and there was a low complication rate. The administration of repeated doses of daclizumab to patients who experience acute postoperative renal failure after heart transplantation may provide an alternative therapeutic approach that enables calcineurin inhibitors to be avoided and, consequently, renal function to recover.

Predictors of renal dysfunction at 1 year in heart transplant patients.

BACKGROUND: Renal dysfunction (RD) is one of the most significant long-term complications of heart transplantation (HT). Although RD is generally attributed to a direct effect of calcineurin inhibitors, it is more probable that multiple factors contribute to its development. The aim of this study was to search for predictor variables of RD at 1 year after HT. METHODS: Three hundred sixteen consecutive HT patients were evaluated. The relationship between RD at 1 year (glomerular filtration rate <60 mL/min/1.73 m2), and pretransplant and 1-year follow-up variables was analyzed. RESULTS: At 1 year following HT, 181 patients (57%) had a glomerular filtration rate of <60 mL/min/1.73 m2. On multivariate analysis, pretransplant serum creatinine values (odds ratio [OR] 5.106, 95% confidence interval [CI]: 2.35-11.09, P=0.0001) and cytomegalovirus (CMV) infection (OR 2.04, 95% CI: 1.08-3.83, P=0.027) were significant predictors of RD, and diabetes mellitus was almost significant (OR 1.65, 95% CI: 0.98-2.76, P=0.055). Variables protective against RD were induction therapy with interleukin-2 receptor antagonists versus muromonab-CD3 (OR 0.389, 95% CI: 0.24-0.61, P=0.0001), maintenance treatment with mycophenolate mofetil versus azathioprine (OR 0.42, 95% CI: 0.26-0.68, P=0.0001), and CMV antiviral prophylaxis (OR 0.38, 95% CI: 0.17-0.68, P=0.021). CONCLUSIONS: Fifty-seven percent of HT patients had RD at 1 year posttransplant. RD was associated with pretransplant serum creatinine values, CMV infection, and diabetes mellitus. Induction with interleukin-2 receptor antagonists, treatment with mycophenolate mofetil, and antiviral prophylaxis for CMV infection all helped maintain renal function in this cohort of HT patients.

Experimental study of the so called left ventricular isovolumic relaxation phase.

INTRODUCTION AND OBJECTIVES: Left ventricular filling begins in the ventricular isovolumic relaxation phase. According to the Torrent-Guasp myocardial band theory, this phase results from the contraction of the final portion of the myocardial band: the ascending segment of the apical loop. The objectives were to study the myocardial mechanisms influencing transmitral flow during early diastole and to determine whether the rapid ventricular filling phase involves contraction or relaxation. METHODS: An experimental in vivo pig model was used. Regional contractility in three segments of the myocardial band was assessed using piezoelectric crystals and mitral flow was measured by echo-Doppler ultrasonography at baseline and after akinesia had been induced in the ascending segment by 2.5% formaldehyde infusion. Changes in intracavitary pressure in the left ventricle and left atrium and flow alterations in the aortic root were recorded. The start of the isovolumic relaxation phase was identified using the time at which the ejection of blood ceases, as indicated by aortic flow measurements. RESULTS: During the left ventricular isovolumetric relaxation phase, the ascending segment of the apical loop was undergoing contraction. The infusion of formaldehyde into this segment affected the extent to which the intraventricular pressure could decrease, prolonged the isovolumic relaxation phase and resulted in a lower minimum pressure. It also produced a significant decrease in transmitral flow velocity in early diastole and an increase at end-diastole. CONCLUSIONS: The rapid ventricular filling phase is characterized by contraction.

Estudio experimental de la llamada fase de relajación isovolumétrica del ventrículo izquierdo / Experimental study of the so called left ventricular isovolumic relaxation phase

Introducción y objetivos. El llenado del ventrículo izquierdo se inicia con la fase de relajación isovolumétrica ventricular. En la teoría de la banda miocárdica de Torrent-Guasp, esta fase se produce como consecuencia de la contracción de la porción final de la banda muscular, el segmento ascendente de la lazada apexiana. El objetivo es estudiar los mecanismos miocárdicos involucrados en el flujo transmitral durante la protodiástole y discernir si la fase de llenado rápido ventricular es un proceso de relajación o de contracción. Métodos. Modelo experimental in vivo en cerdos. Se estudia la contractilidad regional con cristales piezoeléctricos en tres segmentos de la banda miocárdica y el flujo transmitral con eco-Doppler, en situación basal y tras la producción de acinesia del segmento ascendente mediante la infiltración con formaldehído al 2,5%. Se registran las curvas de presión intracavitarias del ventrículo izquierdo y la aurícula izquierda y el flujo en la raíz aórtica. Para determinar el inicio de la fase de relajación isovolumétrica, hemos identificado el final de la expulsión de sangre en la curva del flujo aórtico. Resultados. Durante la fase de relajación isovolumétrica del ventrículo izquierdo, el segmento ascendente de la lazada apexiana está contrayéndose. La infiltración con formaldehído de este segmento afecta a la capacidad de reducir la presión intraventricular, y la duración de la fase de relajación isovolumétrica se prolonga y se alcanza una menor presión mínima. Se produce un descenso significativo en las velocidades del flujo transmitral de la protodiástole y un incremento en la telediástole. Conclusiones. La fase de llenado rápido ventricular es un proceso de contracción (AU)

Introduction and objectives. Left ventricular filling begins in the ventricular isovolumic relaxation phase. According to the Torrent-Guasp myocardial band theory, this phase results from the contraction of the final portion of the myocardial band: the ascending segment of the apical loop. The objectives were to study the myocardial mechanisms influencing transmitral flow during early diastole and to determine whether the rapid ventricular filling phase involves contraction or relaxation. Methods. An experimental in vivo pig model was used. Regional contractility in 3 segments of the myocardial band was assessed using piezoelectric crystals and mitral flow was measured by echo-Doppler ultrasonography at baseline and after akinesia had been induced in the ascending segment by 2.5% formaldehyde infusion. Changes in intracavitary pressure in the left ventricle and left atrium and flow alterations in the aortic root were recorded. The start of the isovolumic relaxation phase was identified using the time at which the ejection of blood ceases, as indicated by aortic flow measurements. Results. During the left ventricular isovolumetric relaxation phase, the ascending segment of the apical loop was undergoing contraction. The infusion of formaldehyde into this segment affected the extent to which the intraventricular pressure could decrease, prolonged the isovolumic relaxation phase and resulted in a lower minimum pressure. It also produced a significant decrease in transmitral flow velocity in early diastole and an increase at end-diastole. Conclusions. The rapid ventricular filling phase is characterized by contraction (AU)