Ángel L. Fernández

Comparación de los efectos hemodinámicos del levosimendán con la dobutamina en pacientes con bajo gasto después de cirugía cardiaca

Introduccion y objetivos El levosimendan es un farmaco inotropico positivo eficaz en la insuficiencia cardiaca. Sin embargo, la experiencia con levosimendan en pacientes con bajo gasto despues de una cirugia cardiaca es reducida. El proposito de este estudio es comparar a corto plazo los efectos hemodinamicos del levosimendan frente a la dobutamina despues de la cirugia cardiaca. Metodos Se estudio a 41 pacientes con bajo gasto despues de una cirugia cardiaca bajo circulacion extracorporea divididos en 2 grupos. Un grupo (nxa0=xa020) recibio una infusion continua de 7,5xa0μg/kg/min de dobutamina durante 24xa0h. Otro grupo (nxa0=xa021) recibio una dosis de carga de levosimendan de 12 μg/kg seguida de una infusion de 0,2xa0μg/kg/min durante 24xa0h. Se determinaron el gasto cardiaco, la frecuencia cardiaca, la presion arterial, la presion venosa central, la presion arterial pulmonar, la presion capilar, la resistencia vascular pulmonar y sistemica, y el volumen sistolico. Resultados Ambos farmacos aumentaron significativamente el indice cardiaco aunque fue mas marcado con el levosimendan (a las 24xa0h, 2,4xa0±xa00,2 frente a 2,9xa0±xa00,3 l/min/m2; pxa0 Conclusiones El levosimendan y la dobutamina son eficaces en el tratamiento del bajo gasto despues de la cirugia cardiaca. Sin embargo, el levosimendan ejerce un efecto vasodilatador inespecifico capaz de provocar hipotension arterial. En estos pacientes es recomendable reducir o suprimir la dosis de carga.

Hemodynamic effects of levosimendan compared with dobutamine in patients with low cardiac output after cardiac surgery

INTRODUCTION AND OBJECTIVESnLevosimendan is an inotropic agent that is effective in the treatment of heart failure. However, experience with levosimendan in patients with reduced cardiac output following cardiopulmonary bypass is limited. The objective of this study was to compare the short-term hemodynamic effects of levosimendan with those of dobutamine in managing low cardiac output after cardiac surgery.nnnMETHODSnForty-one patients who had low cardiac output after cardiopulmonary bypass were randomly assigned to dobutamine (n=20), 24-hour infusion of 7.5 microg/kg per min, or levosimendan (n=21), at a loading dose of 12 microg/kg followed by 24-hour infusion of 0.2 microg/kg per min. The following parameters were determined during a 48-hour observation period: arterial, central venous, pulmonary arterial and pulmonary capillary wedge pressure, cardiac index, heart rate, stroke volume, and systemic and pulmonary vascular resistance.nnnRESULTSnAlthough both dobutamine and levosimendan improved the cardiac index, the increase was significantly greater with levosimendan (2.4 [0.2] l/min per m2 vs 2.9 [0.3] l/min per m2, respectively, at 24 h; P<.05). Moreover, levosimendan significantly reduced systemic and pulmonary vascular resistance, and significantly decreased systemic arterial, pulmonary arterial, pulmonary capillary wedge, and central venous pressure.nnnCONCLUSIONSnBoth dobutamine and levosimendan are effective in managing postoperative low cardiac output. However, levosimendan induces non-specific systemic, venous and pulmonary vasodilation which can result in hypotension as a adverse event. In these patients, it is advisable to omit or reduce the loading dose.

Epicardial adipose tissue expression of adiponectin is lower in patients with hypertension

Low plasma adiponectin levels are related to a higher risk of development of metabolic and cardiovascular disorders, including hypertension (HT). To date, there have been no studies supporting the relationship between epicardial adipose tissue (EAT) expression of adiponectin and HT. We collected samples of EAT from 116 patients undergoing elective cardiac surgery, mostly for coronary artery bypass grafting (n=54), valve surgery (n=49) or both (n=12). Samples of subcutaneous adipose tissue (SAT) were harvested from 85 patients. After RNA isolation, the expression of adiponectin was analysed by real-time retrotranscriptase (RT)-PCR. Baseline clinical data were obtained from medical records. The diagnosis of HT was established mostly by the patients’ general physicians following current guidelines. We included 84 hypertensive and 32 non-hypertensive patients. Mean (±s.d.) age was 70.3±7.9 years. EAT expression levels of adiponectin were lower in hypertensives (14.0±3.6 vs 15.3±3.6 arbitrary units (a.u.), P=0.06). This difference was statistically significant (odds ratio (OR) 0.828 per a.u., P=0.020) after adjustment for age, gender, body mass index, diabetes mellitus, heart failure, coronary artery disease (CAD), total cholesterol and triglyceride levels. However, SAT adiponectin mRNA levels were similar in hypertensive and non-hypertensive patients (15.3±4.2 vs 15.3±5.0 a.u., P>0.99). Adjustment for potential confounding factors hardly altered this result. Our findings indicate that EAT expression of adiponectin may be associated with HT status independently of CAD or other comorbidities, whereas SAT expression does not. These results support the hypothesis that EAT is actively implicated in global cardiovascular risk, describing its association with HT.

Gender Differences in Adiponectin and Leptin Expression in Epicardial and Subcutaneous Adipose Tissue. Findings in Patients Undergoing Cardiac Surgery

INTRODUCTION AND OBJECTIVESnThe high level of metabolic activity present in visceral adipose tissue is associated with the development of atherothrombosis. Subcutaneous adipose tissue secretes larger quantities of the adipocytokines leptin and adiponectin than visceral adipose tissue. Epicardial adipose tissue secretes inflammatory mediators, and the resulting proinflammatory activity is greater than that associated with subcutaneous adipose tissue. The aim of this study was to compare adiponectin and leptin expression in human epicardial and subcutaneous adipose tissue.nnnMETHODSnSamples of both epicardial and subcutaneous adipose tissue were taken from 46 patients who were undergoing heart surgery, coronary artery bypass surgery, or aortic or mitral valve replacement. Levels of protein and gene expression of leptin and adiponectin were assessed immunohistochemically and by RT-PCR, respectively. Levels of mRNA expression in the 2 adipose tissue types were compared by real-time quantitative PCR.nnnRESULTSnSignificant differences were found between adiponectin and leptin mRNA expression in epicardial and subcutaneous adipose tissue, with epicardial adipose tissue exhibiting lower levels of adiponectin and leptin expression. Moreover, adiponectin and leptin mRNA expression in epicardial adipose tissue was higher in women than men.nnnCONCLUSIONSnAdiponectin and leptin expression is lower in epicardial than in subcutaneous adipose tissue. Moreover, there are differences in adiponectin and leptin expression in epicardial adipose tissue between women and men.

Guías de práctica clínica de la Sociedad Española de Cardiología en cirugía coronaria

La cirugia en la cardiopatia isquemica (revascularizacion miocardica y cirugia correctora de las complicaciones mecanicas del infarto agudo de miocardio) mejora la sintomatologia, la calidad de vida y/o el pronostico de determinados grupos de pacientes. El beneficio esperable en cada paciente depende de multiples factores bien conocidos, entre los que destaca la idoneidad de la indicacion. El objetivo de esta guia de practica clinica es revisar las recomendaciones de la cirugia en la enfermedad coronaria mediante la evaluacion del grado de evidencia de su efectividad en cada subgrupo de pacientes, a la luz de los conocimientos actuales (revision sistematica de la bibliografia) y la opinion de expertos recogidos en diversos informes. Se han establecido las indicaciones y el grado de recomendacion de la cirugia de revascularizacion convencional para cada una de las situaciones anatomo-clinicas en las que mas frecuentemente se presenta la enfermedad coronaria. Estas situaciones se han definido en funcion de la clinica (angina estable, inestable o infarto agudo de miocardio), la funcion ventricular y la extension y localizacion de la enfermedad coronaria. Se describen, ademas, los subgrupos de pacientes con mayor riesgo quirurgico y los modelos de estratificacion que sirven de ayuda en la decision en el paciente individual. Se han analizado la base racional y las indicaciones de las nuevas tecnicas quirurgicas, como la cirugia minimamente invasiva y la revascularizacion arterial completa. Por ultimo, se discuten las indicaciones y el momento de la cirugia en los pacientes con complicaciones mecanicas surgidas en el contexto del infarto agudo de miocardio.

High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients

Background:u2002 High thoracic epidural techniques are increasingly being used in patients scheduled for cardiothoracic surgery, including coronary artery bypass grafting. In the present study, we evaluated the acute effects of the epidural blockade on myocardial oxygen availability by means of tissue oxygen pressure monitoring in patients submitted for surgical revascularization.

Orosomucoid secretion levels by epicardial adipose tissue as possible indicator of endothelial dysfunction in diabetes mellitus or inflammation in coronary artery disease

OBJECTIVEnType 2 diabetes mellitus (T2DM) is associated with fat and autonomic system dysfunction. Epicardial adipose tissue (EAT) plays an endocrine role over the heart. Since orosomucoid (ORM) has local actions around the coronaries, our aim was to assess the relationship between its secretion profile by EAT and its catecholaminergic regulation in patients with T2DM and coronary artery disease (CAD).nnnMETHODSnWe obtained EAT, subcutaneous adipose tissue (SAT) and plasma from 55 patients undergoing cardiac surgery. Fat explants were stimulated with isoproterenol (ISO) 1xa0μM for 6xa0h. After, the fat explants released-ORM and plasma levels were analyzed by ELISA. mRNA or protein expression was analyzed by real time PCR or western blot, respectively. The effects of ORM on endothelial cells were analyzed by impedance and wound healing assays.nnnRESULTSnWe observed that EAT-released ORM levels were higher than SAT (328xa0±xa0185 vs 58xa0±xa045xa0ng/mL; pxa0<xa00.001). Interestingly, EAT secretion was lower in patients with than those without T2DM (260xa0±xa0141 vs 370xa0±xa0194xa0ng/mL; pxa0<xa00.05) and this difference was enhanced after ISO stimulation (pxa0<xa00.01). However, plasma levels (412xa0±xa0119 vs 594xa0±xa0207xa0μg/mL) and EAT-released ORM levels were higher in patients with than those without CAD (384xa0±xa0195 vs 279xa0±xa0159xa0ng/mL; pxa0<xa00.05). ISO stimulation, also reduced the EAT released-ORM levels in patients with CAD. On human endothelial cells, ORM induced an increase of healing and proliferation in a dose-dependent manner.nnnCONCLUSIONnEAT-released ORM levels in patients with T2DM or CAD and its regulation by catecholamines might be the mirror of local endothelium dysfunction or inflammatory process in different cardiovascular disorders.

Impaired Adipogenesis and Insulin Resistance in Epicardial Fat-Mesenchymal Cells From Patients With Cardiovascular Disease

The thickness of epicardial adipose tissue (EAT), which is an inflammatory source for coronary artery disease (CAD), correlates with insulin resistance. One trigger factor is impaired adipogenesis. Here, our aim was to clarify the underlying mechanisms of insulin resistance on EAT‐mesenchymal cells (MC). EAT and subcutaneous adipose tissue (SAT) were collected from 19 patients who were undergoing heart surgery. Their dedifferentiated adipocytes (DAs) and/or MCs were cultured. After the induction of adipogenesis or stimulation with insulin, the expression of adipokines was analyzed using real‐time polymerase chain reaction (PCR). Colorimetric assays were performed to measure glucose levels and proliferation rate. Proteins modifications were detected via the proteomic approach and Western blot. Our results showed lower adipogenic ability in EAT‐MCs than in SAT‐MCs. Maximum adiponectin levels were reached within 28–35 days of exposure to adipogenic inducers. Moreover, the adipogenesis profile in EAT‐MCs was dependent on the patients’ clinical characteristics. The low adipogenic ability of EAT‐MCs might be associated with an insulin‐resistant state because chronic insulin treatment reduced the inflammatory cytokine expression levels, improved the glucose consumption, and increased the post‐translational modifications (PTMs) of the glycolytic enzyme phosphoglycerate mutase 1 (PGAM1). We found lower adipogenic ability in EAT‐MCs than in SAT‐MCs. This lower ability level was dependent on gender and the presence of diabetes, obesity, and CAD. Low adipogenesis ability and insulin resistance in EAT‐MCs might shed light on the association between EAT dysfunction and cardiovascular disease. J. Cell. Physiol. 229: 1722–1730, 2014.

Myxoma of the aortic valve

Myxomatous tumours can arise from different cardiac structures. They have a special predilection for the left atrium and are an exceedingly uncommon finding in cardiac valves. We report the case of a 28-year old man who presented with a stroke and was found to have a mass arising from his aortic valve. The patient underwent a successful surgical excision of the aortic valve with the implantation of a mechanical prosthesis. The histopathological examination of the aortic valve confirmed the diagnosis of myxoma. Some aspects related to the diagnosis and management of this entity are discussed in this article.

Glucose and Inflammatory Cells Decrease Adiponectin in Epicardial Adipose Tissue Cells: Paracrine Consequences on Vascular Endothelium.

Epicardial adipose tissue (EAT) is a source of energy for heart that expresses the insulin‐sensitizer, anti‐inflammatory and anti‐atherogenic protein, adiponectin. But, in coronary artery disease, adiponectin production declines. Our objective was to determine its regulation by glucose and inflammation in stromal cells from EAT and subcutaneous adipose tissue (SAT) and its paracrine effect on endothelial cells. Stromal cells of EAT and SAT were obtained from patients who underwent cardiac surgery. Adipogenesis was induced at 117, 200, or 295u2009mg/dl glucose, with or without macrophage‐conditioned medium (MCM). Expression of adiponectin, GLUT‐4 and the insulin receptor was analyzed by real‐time PCR. The paracrine effect of stromal cells was determined in co‐cultures with endothelial cells, by exposing them to high glucose and/or MCM, and, additionally, to leukocyte‐conditioned medium from patients with myocardial infarction. The endothelial response was determined by analyzing vascular adhesion molecule expression. Our results showed a U‐shaped dose–response curve of glucose on adiponectin in EAT, but not in SAT stromal cells. Conversely, MCM reduced the adipogenesis‐induced adiponectin expression of EAT stromal cells. The presence of EAT stromal increased the inflammatory molecules of endothelial cells. This deleterious effect was emphasized in the presence of inflammatory cell‐conditioned medium from patients with myocardial infarction. Thus, high glucose and inflammatory cells reduced adipogenesis‐induced adiponectin expression of EAT stromal cells, which induced an inflammatory paracrine process in endothelial cells. This inflammatory effect was lower in presence of mature adipocytes, producers of adiponectin. These results contribute to understanding the role of EAT dysfunction on coronary atherosclerosis progression. J. Cell. Physiol. 231: 1015–1023, 2016.