Accuracy of noninvasive estimation of pulmonary wedge pressure by echocardiographic indices in heart transplant recipients.

BACKGROUND: Pulmonary capillary wedge pressure (PCWP) can be estimated from transmitral or color M-mode Doppler flow propagation velocities. However, it has been recommended to not use these indices in heart transplant recipients. Our aim was to compare the accuracy of color M-mode, Doppler, and Doppler tissue imaging (DTI)-derived indices to predict PCWP in heart transplant recipients. METHODS: We studied 50 consecutive heart transplant recipients scheduled for routine right-sided heart catheterization and endomyocardial biopsy. Their mean age was 49 ± 17 years and the mean time after heart transplantation was 29 ± 41 months. An echocardiogram was performed immediately after the invasive procedure. We analysed PCWP, transmitral flow velocity variables (peak velocity during early filling (E) and deceleration time [DT]), color M-mode Doppler flow propagation velocity (Vp), and mitral annulus peak early diastolic velocity (E') from DTI. Doppler estimated-PCWP (ePCWP) was calculated as follows: (5.27 × E/Vp) + 4.6. RESULTS: Mean ejection fraction was 66 ± 11%. The mean invasive measured PCWP was 11.14 ± 5.4 mm Hg and the mean noninvasive ePCWP was 11.13 ± 1.8 mm Hg (r = 0.66; P < .0001). A good correlation was present between invasive PCWP and mitral PW-Doppler and DTI parameters: peak E 91 ± 22 cm/s (r = 0.34; P = .02) and DT 143 ± 26 s (r = -0.436; P = .002), E/E' ratio medial mitral annulus 10 ± 4 cm/s (r = 0.353; P = .026) and E/E' ratio lateral mitral annulus 6 ± 2 cm/s (r = 0.462; P = .002). E/Vp was the most accurate index for predicting PCWP (r = 0.615; P < .0001). CONCLUSIONS: Compared with other indirect Doppler indices, E/Vp showed the best correlation to predict PCWP in heart transplant recipients. Despite previous recommendations, PCWP can be accurately estimated from color M-mode indices, giving useful information and avoiding the risks of invasive measurements.

Effect of different pharmacologic agents to reverse severe pulmonary hypertension among end-stage heart failure patients.

OBJECTIVE: The goal of this study was to analyze the hemodynamic responses during vasoreactivity tests among candidates for heart transplantation who displayed severe pulmonary hypertension seeking to identify risk markers of nonresponse to the test. MATERIALS AND METHODS: In this observational retrospective study we evaluated demographic, clinical, echocardiographic, and hemodynamic variables. The target hemodynamic goal in the vasoreactivity test was to achieve a transpulmonary gradient (TPG) <12 mm Hg and/or pulmonary vascular resistances (PVR) <2.5 Wood Units (WU). RESULTS: We analyzed medical records from 79 patients. Inotropes (dopamine or dobutamine) were used to treat 33 patients, nonselective vasodilators (nitroglycerin or sodium nitroprusside) were used in 22 patients, and prostacyclin (PC) was used in 24 patients. The study observed a significant decrease in pulmonary pressures, PVR, and TPG, with increased cardiac output (CO) compared with baseline hemodynamics in all groups. No significant differences were observed between agents except for an increase in CO, which was greater in the PC group. Also, 49.4% of patients were considered responders to the vasoreactivity test without significant differences between groups. Risk markers for absence of a response to the vasoreactivity test were a CO <2.5 L/min (odds ratio [OR] = 2.1; confidence interval [CI] 95%, 1.1-3.9; P = .035) and a PVR >6 WU (OR = 3.7; CI 95%, 1.8-7.6; P < .001) in the baseline hemodynamic study. CONCLUSIONS: Inotropes, nonselective vasodilators, and prostacyclin produced effective vasodilator responses in the pulmonary vascular bed during the vasoreactivity test. The presence of a baseline high PVR or a low CO were predictors of nonresponse to the test.

[Sildenafil as a substitute for subcutaneous prostacyclin in pulmonary hypertension]. / Sildenafilo como sustituto de prostaciclina subcutánea en la hepertensión pulmonar.

Subcutaneous prostacyclin (treprostinil) is an effective short-term treatment for pulmonary hypertension. The most frequently described adverse effect-pain in the area of injection-rarely requires that treatment be withdrawn. Sildenafil is a selective fosfodiesterase-5 inhibitor with pulmonary vasodilating effects. We describe the use of sildenafil as a substitute for treprostinil in a patient with pulmonary hypertension associated with lupus erythematosus. Treatment with treprostinil was discontinued due to uncontrollable abdominal pain.

Sildenafilo como sustituto de prostaciclina subcutánea en la hipertensión pulmonar / Sildenafil as a substitute for subcutaneous prostacyclin in pulmonary hypertension

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Successful heart transplantation in patients with inherited myopathies associated with end-stage cardiomyopathy.

UNLABELLED: Inherited myopathies in patients with secondary end-stage cardiomyopathies have always been considered a relative contraindication for cardiac transplantation. High operative risk related to muscle impairment and potential graft involvement secondary to the underlying myopathy have been the two main reasons implicated in the poor prognosis. OBJECTIVE: The aim of this study was to evaluate the outcome in patients who underwent cardiac transplantation in our hospital due to end-stage cardiomyopathy secondary to inherited myopathies. METHODS: Among 311 patients who underwent heart transplantation in our hospital, five (2%) had end-stage cardiomyopathies related to inherited myopathies. Four patients had muscular dystrophy (three Becker's muscular dystrophy and one hips-dystrophy) and the fifth desminopathy. In one patient cardiomyopathy was the initial manifestation of the disease. Mean age at the time of transplantation was 38.6 years (range from 24 to 55). The mean follow-up after transplantation was 57.4 months (range from 13 to 128). The intraoperative and postoperative course of these individuals did not show higher complication rates than other patients. All recipients experienced successful rehabilitation; no evidence of graft dysfunction has been detected during follow-up. All of them are alive with a good performance status. CONCLUSIONS: In our experience, patients who underwent heart transplantation due to end-stage cardiomyopathy secondary to inherited myopathy with only a mild degree of muscle impairment did not display higher postoperative nor long-term complications compared to other recipients.

[Diastolic dysfunction in human immunodeficiency virus infection]. / Disfunción diastólica en la infección por el virus de la inmunodeficiencia humana.

AIMS: We sought to determine the prevalence and characteristics of echocardiographic abnormalities (systolic and/or diastolic dysfunction, pericardial effusion) in patients with human immunodeficiency virus infection (HIV) with no symptoms or previous history of cardiac disease, and compare them with a healthy control group. PATIENTS AND METHOD: Transthoracic echocardiography was performed in 125 patients (73% male, mean age 33.2 +/- 6.6 years) with HIV infection without cardiac involvement and 47 age and sex-matched healthy volunteers (78% male, 31.6 +/- 7.3 years). The immunologic situation was determined by CD4 lymphocyte counts. RESULTS: Abnormal left ventricular relaxation and filling patterns (E/A relation 1.31 +/- 0.35 in HIV group, 1.66 +/- 0.38 in control group, p < 0.001; pressure half-time 57.5 +/- 13 in HIV group, 50.6 +/- 6.6 in control group, p < 0.001), segmental wall-motion abnormalities (15%) and pericardial effusion (7.2%) were found in patients with HIV infection. Systolic function (EF 64.8 +/- 8.3) and left ventricular dimension (diastolic diameter 4.94 +/- 0.55, systolic diameter 3.17 +/- 0.51) showed normal patterns and did not significantly differ from those of the control group. CONCLUSIONS: Silent echocardiographic abnormalities in patients with HIV infection are frequent suggesting a direct myocardial effect of the virus. The development of diastolic dysfunction is directly related to a worse immunologic situation. Prospective studies are needed to clarify the clinical prognosis of these asymptomatic abnormalities.

[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.

Impact of mild pulmonary hypertension on mortality and pulmonary artery pressure profile after heart transplantation.

BACKGROUND: Pulmonary hypertension is a risk factor for early mortality after transplantation, but the risk threshold is debated. Also, little is known about the evolution of pulmonary circulation after transplantation. The aim of this study was to determine the influence of current risk pulmonary pressure parameters on early post-operative mortality and to assess the time-related changes in pulmonary pressure after surgery. METHODS: One hundred twelve consecutive transplanted patients were studied retrospectively to determine the influence of trans-pulmonary gradient of >12 mm Hg and pulmonary vascular resistance of >2.5 Wood units, at baseline or after vasodilator test, on early mortality. A multivariate analysis was used to study the hemodynamic parameters associated with early mortality. The pulmonary pressures of all surviving patients were studied for up to 3 years after surgery. RESULTS: Early mortality in the groups with and without pulmonary hypertension were 24.4% and 5.6%, respectively (p =.009). The only variable that was independently associated with early mortality was the pulmonary vascular resistance index (odds ratio = 1.459). Mild pulmonary hypertension disappeared 1 year after heart transplantation. CONCLUSIONS: Mild pulmonary hypertension is a risk factor for early postoperative mortality. The hemodynamic parameter most closely associated with early mortality is pulmonary vascular resistance index. The hemodynamic profile of pulmonary circulation after heart transplantation is partially dependent on the level of pulmonary hypertension before transplantation, at least during the first year after surgery.

[Coordination between primary and cardiological care: the opinion of the family doctor]. / La coordinación entre asistencia primaria y cardiología. La opinión del médico de familia.

OBJECTIVE: To analyse the relationship between Primary and Cardiological Care from the perspective of family physicians. METHODS: A descriptive-crossover study was carried out by a questionnaire sent by mail to a sample of 384 doctors systematically selected from the database of the College of Physicians of Madrid. RESULTS: One hundred forty-eight physicians (38.5%) answered the questionnaire, 75% of whom saw more than 30 patients/week with cardiovascular risk factors and more than 10 patients/week with cardiac syndromes, in the following order: ischaemic heart disease, heart failure, arrhythmias, valvular disease, cor pulmonale and others. Ninety percent of the physicians refer less than 10 patients/month to cardiologists, with a time delay of greater than a month in 50% of the cases. The document used for referral is the consultation form (98%) that is always or frequently answered. The quality of the cardiologist's report is either good or excellent in 50% of the cases. Accessibility to electrocardiograms and thorax x-rays by family doctors is of 99.3%. Family physicians have a very positive opinion regarding the need for hospital collaboration in their continuous training and coordination with cardiologists.

Manejo del enfermo con miocardiopatía dilatada y miocarditis / Management of the patient with dilated myocardiopathy and myocarditis

La miocardiopatía dilatada (MCD) es una enfermedad intrínseca del miocardio, caracterizada por la dilatación del ventrículo izquierdo o de ambos ventrículos, así como por la disminución de su contractilidad. Es más frecuente en varones en la edad media de la vida, pero debido a que en las fases iniciales suele cursar de forma asintomática, su incidencia puede estar infraestimada. Se han identificado múltiples etiologías causantes de MCD, y todo apunta a que diversos factores pueden influir conjuntamente en producirla. Con frecuencia no se encuentra el agente causal y entonces se denomina MCD idiopática. Su presentación clínica es muy variada, pero la manifestación más frecuente es la insuficiencia cardíaca (IC), que se agrava conforme evoluciona la enfermedad.El manejo de los pacientes con MCD consiste en retrasar la progresión hacia la IC y disminuir la morbimortalidad.La miocarditis es un proceso inflamatorio no isquémico del miocardio, debido a un amplio y heterogéneo grupo de agentes etiológicos con variada distribución geográfica, lo que afecta a la incidencia y prevalencia de la enfermedad. Existe una fase inicial de agresión al miocardio, que suele seguirse de curación o de una segunda fase de inflamación crónica mediada por mecanismos autoinmunes, asociados o no a la persistencia del agente causal. La clínica varía desde la curación completa hasta la evolución hacia MCD. Su tratamiento es sintomático incluyendo el manejo y prevención de las complicaciones. Actualmente se investiga con la terapia inmunosupresora, basándose en la posible perpetuación del daño miocárdico por mecanismos autoinmunes. (AU)

Insuficiencia cardiaca. Un problema de salud pública / Heart failure: a problem of public health

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[Quality of life and social support in patients with non-complicated acute myocardial infarct]. / Calidad de vida y apoyo social en pacientes con infarto agudo de miocardio no complicado.

INTRODUCTION: There is a relationship between social support and health. However, there is no very much available research in the area of ischemic heart disease related to the influence of social support on the quality of life. OBJECTIVES: To study the social aspects of patients. To measure emotional and instrumental social support and quality of life, after a first acute myocardial infarction. PATIENTS AND METHODS: 155 patients were studied under two pieces of assessment: at admission's time and six months later. A protocol was selected with clinical, socio-economic, social support and quality of life variables. RESULTS: 90.9% could read and write, however 42.3% have any study or completed their primary studies. Moreover, 45.1% of patients were working, at six months only 14% of them had returned to their jobs. They were blue and white collar patients. Availability of instrumental and emotional social support was referred by 78.7% and 69.9% respectively of patient's. At the beginning, the mean quality of life was 108.1 +/- 19.3. Six months later was 101.1 +/- 19.1 SD. Statistics revealed that the availability of instrumental and emotional social support impacts favourably on human being's health. CONCLUSIONS: The quality of life is related to the patient's perceived social support. The perceived social support depends directly on the size of their network. Moreover, there is a relationship between quality of life and educational achievement, so that, the lower that patient's quality of life, the lower the educational achievement. After the first not complicated myocardial infarction the return to their jobs is really low.

[An anomalous origin of the left coronary artery associated with a right coronary spasm as the cause of angina and presyncope]. / Origen anómalo de la arteria coronaria izquierda asociado a espasmo de la coronaria derecha como causa de angina y presíncope.

We describe the rare association of angina at effort and presyncope in a young patient with an anomalous origin of left coronary artery and associated coronary spasm in the normal right coronary artery. The patient did well under calcium channel blocker therapy after seven years of follow-up, which is in contrast with the usual recommended management of these patients.

[Hypertension and dyslipidemia]. / Hipertensión y dislipemia.

Hypertension is a very important cardiovascular risk factor and directly leads to major atherosclerotic cardiovascular diseases, including coronary artery disease, stroke cardiac failure and peripheral artery disease. Hypertension tends to cluster with other atherogenic risk factors like dyslipidemia, insulin resistance, obesity and others. The association between hypertension and dyslipidemia is very frequent and the risk is more than additive and its possible pathogenesis may be of a common mechanism. Insulin resistance is the main cause of both risk factors. Endothelium dysfunction is present in arterial hypertension and dyslipidemia and the pathogenesis of atherosclerosis. The treatment of hypertensive patients must be individualized to accommodate both the concomitant dyslipidemia and other atherogenic factors.