Ana Osa

Thrombin‐activatable fibrinolysis inhibitor in young patients with myocardial infarction and its relationship with the fibrinolytic function and the protein C system

Summary. Thrombin‐activatable fibrinolysis inhibitor (TAFI) is a fibrinolytic inhibitor. Studies in coronary artery disease have reported increased TAFI activity (TAFI Act) and low TAFI antigen (TAFI Ag) levels. This controversy might be explained by the polymorphisms of its gene. Only the Thr325Ile polymorphism modulates both TAFI Ag and Act levels in vitro. This study assessed TAFI Ag and Act levels, TAFI Thr325Ile polymorphism, the fibrinolytic and protein C systems and some prothrombotic mutations in a young patient group (n = 127, aged < 51 years, with myocardial infarction) and a control group (n = 99) with similar characteristics. Patients exhibited hypofibrinolysis and higher plasminogen activator inhibitor‐1 (PAI‐1) levels. Although TAFI Ag was lower, TAFI Act level was significantly higher in patients and positively correlated with PAI‐1, protein C inhibitor and the euglobulin lysis time. No differences between groups were found according to the Thr325Ile polymorphism. Irrespective of the genotype, patients had higher TAFI Act levels. The Ile‐325 variant exhibited lower TAFI Ag levels. We suggest that the hypofibrinolysis observed in these patients results from an increase in both PAI‐1 and TAFI Act, which is not related to the Thr325Ile polymorphism. Patients have high TAFI Act with low TAFI Ag levels, probably because of an increased stability of TAFI related to a fibrinolytic hypofunction.

Ventricular natriuretic peptide (BNP) in heart transplantation: BNP correlation with endomyocardial biopsy, laboratory and hemodynamic measures

A prospective study of 81 heart transplant (HT) patients was carried out in order to evaluate the evolution of brain natriuretic peptide (BNP) levels in HT patients and compare them with the degree of rejection as determined by endomyocardial biopsy. All patients were subjected to endomyocardial biopsy (532), and determination of BNP and creatinine levels as well as hemodynamic parameters. A control group of 36 volunteers was included. BNP values were significantly greater in HT patients than in healthy volunteers. In the first 3 months, BNP levels in patients with treatable rejection were significantly greater than in patients without graft rejection, although evident overlapping was observed in both distributions and discriminatory potential was low. After the third month, BNP values were similar in patients with and without rejection. Creatinine levels were observed to increase over time after transplantation, but no correlation was observed between the creatinine and BNP levels. A significant positive correlation was observed between BNP and right ventricle and pulmonary arterial pressures.

Utilidad del electrocardiograma para predecir el lugar de la oclusión en el infarto agudo de miocardio anterior con enfermedad aislada de la arteria descendente anterior

Introduccion y objetivos En el infarto agudo de miocardio (IAM) anterior, el lugar de la oclusion de la arteria descendente anterior (DA) se relaciona con la extension de la necrosis y con el pronostico. El proposito del estudio fue valorar la utilidad del electrocardiograma (ECG) para predecir el lugar de la oclusion de la DA en pacientes con IAM anterior y enfermedad aislada de la DA. Metodos Estudio retrospectivo en el que se incluyen a 45 pacientes consecutivos con un primer IAM de localizacion anterior y enfermedad aislada de la DA. Analizamos el ECG que mostro la mayor desviacion del segmento ST (ST) previo al tratamiento fibrinolitico y lo correlacionamos con el nivel lesional en la DA en coronariografia realizada antes del alta hospitalaria en relacion con la primera septal dominante y primera diagonal, distinguiendo: territorio septal afectado («S»), territorio diagonal afectado («D»), ambos afectados («S + D») o ninguno. Resultados El descenso del segmento ST en las derivaciones II, III o aVF fue un potente predictor de lesion proximal en la DA en las localizaciones angiograficas «S + D», «S» y «D» (p = 0,003, p = 0,04 y p = 0,02, respectivamente). El ascenso del ST en II, III o aVF unicamente se observo en pacientes con una DA desarrollada que daba la vuelta al apex y se relaciono con lesion distal a la diagonal dominante (p Conclusiones En el IAM anterior y enfermedad exclusiva de la DA, el ECG puede ser una herramienta util en la prediccion del nivel lesional de la DA en relacion con sus ramas principales.

Variables predictoras de mortalidad precoz tras el trasplante cardíaco ortotópico en adultos

Objetivo El proposito de este estudio fue analizarvariables del donante, receptor y quirurgicaspara descubrir factores que pudieran predecir mortalidaddurante la fase precoz ( Material y metodo Se analizaron 125 trasplantescardiacos ortotopicos consecutivos de adultos. Laedad media fue de 51 ± 11 anos (rango, 12-67), 109fueron varones (87%) y 16 mujeres (13%). Se compararondos grupos segun los pacientes hubieranfallecido o no durante los primeros 30 dias tras eltrasplante cardiaco (15 y 110 pacientes, respectivamente). Protocolo inmunosupresor: en el preoperatorio,ciclosporina mas azatioprina. En el intraoperatorio,metilprednisolona. En el postoperatorio, metilprednisolona(primeras 24 h), anticuerpos monoclonalesantilinfociticos (7-10 dias posterioresal trasplante), ciclosporina, azatioprina y corticoides. Se analizaron los siguientes parametros del receptor:sexo, edad, peso, talla, perimetro toracico,cardiopatia de base, intervenciones toracicas previas,estadio funcional o necesidad de catecolaminaslos dias previos al trasplante, presiones y resistenciaspulmonares, historia de hipertensionarterial sistemica, elevacion de creatinina, gruposanguineo, trasplante realizado de forma urgente yrelacion de peso receptor/donante. Se analizaronlos siguientes parametros del donante y la intervencion:sexo, edad, peso, perimetro toracico, diasde estancia en cuidados criticos, dosis de dopaminay dobutamina, grupo sanguineo, procedencia delorgano, causa de muerte, tiempo de isquemia y circulacionextracorporea y tipo de cardioplejia. Resultados La tasa de mortalidad precoz ennuestra serie fue del 12%. En el analisis univariantese observaron diferencias en cuanto a los antecedentesde cirugia cardiovascular, grupo sanguineodel receptor, necesidad de realizar eltrasplante de una forma urgente, resistencias vascularespulmonares superiores a 2,5 UW, tiempo decirculacion extracorporea y la relacion de pesosentre el receptor y el donante. Se aproximo a lasignificacion la causa de muerte del donante. Elanalisis multivariante senalo, como parametros convalor predictivo independiente de mortalidad precoz,los antecedentes de intervencion con circulacionextracorporea, las resistencias vascularespulmonares elevadas, el trasplante urgente, la relacionde pesos receptor/donante y el tiempo de circulacionextracorporea. Conclusiones Pensamos que los resultados denuestra experiencia pueden ayudar a estratificar elriesgo ante un receptor de trasplante cardiaco ortotopico,e incluso contraindicar el procedimientoen determinados casos con acumulacion de factoresde mal pronostico en receptores «limite».

Análisis de los factores que pueden influir en la aparición del fallo agudo del corazón trasplantado

Introduction and objective. Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF. Material and method. In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model. Results. The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01). Conclusions. AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

Is the prognosis poorer in heart transplanted patients who develop a right bundle branch block

BACKGROUND Currently studies conflict on the impact on mortality of right bundle branch block development after transplantation. Most studies conclude that right bundle branch block does not affect patient survival. However, no distinction is made between patients in whom right bundle branch block progresses and those in whom it remains unchanged during follow-up. The objective of this study is to assess clinical or survival differences between patients who develop right bundle branch block and those who do not, and also to analyze these differences depending on progression of this conduction abnormality. MATERIALS AND METHODS Ninety-seven consecutive heart transplant recipients with more than 1 years survival were analyzed. Twelve-lead standard ECGs were performed during the first week after transplantation, which allowed for classification of patients depending on the presence or absence of right bundle branch block. Subsequently, throughout the first year, 2 groups were identified, depending on increase of the conduction defect. The groups were compared and factors determining the presence of right bundle branch block and progression of the conduction defect were found. Survival curves for the conduction defect were also compared. RESULTS Fifty percent of the patients developed right bundle branch block after transplantation; it was progressive in 10. Progressive right bundle branch block was related to greater renal dysfunction (odds ration [OR] = 10.8; confidence interval [CI] = 2-58; p = 0.006), a larger number of rejections (p = 0.01), and a greater death rate (OR = 12.8; CI = 2.5-64; p = 0.002). The presence of progressive right bundle branch block was an independent predictor of long-term mortality (OR = 27.9; CI = 4.2-186.3; p = 0.0006). CONCLUSIONS The development of right bundle branch block after transplantation is related to intraoperative factors and to a greater number of rejections. The presence of this conduction disorder, particularly if it progresses during the first year, identifies a sub-group of patients with a poorer long-term prognosis.

The presence of epsilon waves in a patient with acute right ventricular infarction

Epsilon wave is an unusual electrocardiographical finding, which may appear in other pathological conditions besides the arrhythmogenic right ventricular dysplasia, particularly in the acute myocardial infarction of the right ventricle, the inferior, or the posterior wall of the left ventricle. Its real incidence in these acute coronary syndromes remains unknown and will be probably difficult to assert, since it may be unnoticed by inexperienced physicians because of its little voltage. The outstanding interest of this case lies in the clear electrocardiographical images and in the step‐by‐step differential diagnosis discussed by the authors.

Resultados a largo plazo de la valvuloplastia mitral percutánea

Objetivo Valorar la eficacia a largo plazo de la valvuloplastia mitral percutanea en nuestro centro, asi como evaluar la existencia de predictores de supervivencia libre de eventos cardiovasculares a largo plazo. Pacientes y metodos Entre 1990 y 1996 se han realizado 204 valvuloplastias mitrales con cateter balon de Inoue. La poblacion de estudio esta constituida por 132 pacientes con un seguimiento superior a 9 meses. El seguimiento medio fue de 2,6-1,5 anos (7 dias-5,7 anos). Los objetivos finales de este estudio fueron la necesidad de cirugia mitral, la muerte y la situacion funcional III-IV durante el seguimiento. Se realizo un analisis de la supervivencia determinando la existencia de factores predictores independientes de la supervivencia libre de eventos. Resultados Al finalizar el seguimiento un 88% de los pacientes se encontraban en clase funcional I-II de la New York Heart Association y libres de eventos. El analisis multivariado determino como factores predictores independientes de la aparicion de eventos cardiovasculares a largo plazo la mayor rigidez y engrosamiento valvular, la existencia de una auricula izquierda severamente dilatada, como factores previos a la valvuloplastia mitral percutanea y la obtencion de un resultado suboptimo y la insuficiencia mitral significativa tras la valvuloplastia mitral percutanea. Conclusiones La valvuloplastia mitral percutanea con cateter balon de Inoue es una tecnica segura y eficaz, cuya eficacia se mantiene a largo plazo; los mejores resultados a largo plazo se obtienen en pacientes con valvulas flexibles y poco engrosadas, con auricula izquierda leve o moderadamente aumentada y en aquellos en los que el resultado se considera optimo y no presentan una insuficiencia mitral severa como complicacion del procedimiento.

Value of the Electrocardiogram as a Predictor of Right Ventricular Dysfunction in Patients With Chronic Right Ventricular Volume Overload

INTRODUCTION AND OBJECTIVES Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. METHODS We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. RESULTS We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140ms was found to be the only independent predictor of right ventricular dilation and dysfunction. CONCLUSIONS Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement.

Triple cardiac rupture

Left ventricular free wall rupture and acute ischaemic mitral regurgitation are nowadays rare, but still potentially lethal mechanical complications after acute myocardial infarction. We report a case of a sequential left ventricular free wall rupture, anterolateral papillary muscle disruption, secondary severe mitral regurgitation and subsequent posteromedial papillary muscle head rupture in a single patient during the same ischaemic episode after myocardial infarction, and their related successful surgical procedures and management until discharge. Prompt bedside diagnosis and emergent consecutive surgical procedures, as well as temporary left ventricular assistance, were crucial in the survival of this patient.