Anne Vorlat

Isolated non-compaction of the left ventricle: a rare indication for transplantation

This report describes the diagnostic difficulty encountered in a young female patient presenting with neurologic symptoms, atrial fibrillation and severe left ventricular systolic dysfunction, eventually leading to cardiac transplantation. The scrutiny used in the evaluation of the particular aspect of the left ventricle, and the integration of the information obtained from echocardiography, angiography and magnetic resonance imaging, led to the diagnosis of a rare and mostly unknown cause of cardiac failure. The correct identification of this entity is mandatory because enhanced risk of thromboembolism and malignant arrhythmia should be anticipated. A review of the literature revealed only 6 patients in whom isolated non-compaction of the left ventricle was treated by heart transplantation.

Screening for solid organ malignancies prior to heart transplantation

Background. Prognosis of solid organ cancer in immunosuppressed hostsis generally dismal. Therefore, every effort to identify patients withasymptomatic carcinomas before transplantation should beencouraged. Methods. Sixty-seven patients referred for heart transplantationwere examined adhering to the scheme proposed at the 24th Bethesda Conference.To increase the sensitivity of this work-up, the following items were added:tumor marker assays (prostate-specific antigen in males, carcino embryogenicantigen), abdominal ultrasound, CT scan of the abdomen and the thorax,mammography/echography of the breasts, PAP smear, colonoscopy if carcinoembryogenic antigen abnormal or occult blood in stool, prostate echography ifprostate-specific antigen abnormal or prostatehypertrophy. Results. Carcinoma was detected in 10 of the 67 patients; for 8patients of this cancer group, transplantation was denied. Importantly, 9 ofthe 10 malignancies were detected by means of the diagnostic items that wereadded to the standard screening protocol. There were no significantdifferences between the cancer and the non-cancer group regarding mean age,sex, etiology of heart failure, and smoking history. Stratifying patients inyounger (i.e., ≤54 years) and older (i.e., ≥55 years) age groups showeda significantly greater proportion of older patients in the cancer group(8/10=80%) compared to the non-cancer group (25/57=44%), P =0.04. After a mean follow-upof 34 months, 5 of the 36 transplanted patients developed a malignancy (4 skincarcinomas, 1 non-Hodgkin lymphoma). There have been no malignancy-relateddeaths untilnow. Conclusion. The importance of a thorough screening program in thetriage of candidates with preexisting malignancies, especially in an olderpatient population, is illustrated in thisreport.

Regular use of margarine-containing stanol/sterol esters reduces total and low-density lipoprotein (LDL) cholesterol and allows reduction of statin therapy after cardiac transplantation: preliminary observations

Seventeen stable cardiac transplant recipients, of whom 16 were on statin therapy, used margarine with stanol/sterol esters. Total cholesterol in the treatment group was lowered from 211 mg/dl (range 168 to 244) to 177 mg/dl (136 to 241) (17% reduction, p = 0.003) and low-density lipoprotein (LDL) cholesterol was reduced from 125 mg/dl (73 to 161) to 98 mg/dl (57 to 146) (22% reduction, p = 0.0006). LDL cholesterol reached the pre-defined cut-off level of 115 mg/dl in 12 of 17 patients and statin dosages were reduced. In 8 of 12 patients, LDL cholesterol remained at <115 mg/dl 6 weeks after statin reduction.

Donor B-type natriuretic peptide predicts early cardiac performance after heart transplantation

BACKGROUND Decision processes in heart donation remain difficult and are often based on subjective evaluation. We measured B-type natriuretic peptide (BNP) in heart donors and analyzed its value as a discriminator for early post-transplant cardiac performance. METHODS Blood samples were prospectively obtained in 94 brain-dead patients, among whom 56 were scheduled for heart donation. BNP values were not available prior to donor selection. BNP of heart donors was related to invasively measured cardiac output and hemodynamic parameters, early after transplantation. RESULTS BNP, expressed as median (interquartile range), was 65 (32 to 149) pg/ml in brain-dead donors scheduled for heart donation. BNP was higher (287 pg/ml, range 65 to 457; p = 0.0001) in donors considered ineligible for heart donation. In 45 heart recipients, cardiac output (CO) of 5.6 (4.8 to 6.2) liters/min was measured at Day 12 (10-15). In the univariate analysis, recipient CO correlated significantly with donor BNP (r = -0.34, p = 0.025). Stepwise multiple regression, including donor variables such as body mass index, age, BNP, norepinephrine dose, gender and total ischemic time, identified donor BNP and age as the best independent predictors of CO in recipients (p = 0.02 and p = 0.005, respectively, R(2) of the model = 0.27). Donor BNP of >160 pg/ml had 89% accuracy to predict poor cardiac performance in the recipient (cardiac index <2.2 liters/min/m(2)). High donor BNP was independently correlated with a longer hospital stay. CONCLUSIONS Donor BNP was found to be related to cardiac performance, early after cardiac transplantation. BNP measurement in heart donors could become a useful tool in the evaluation of donor hearts.

TIMI risk score underestimates prognosis in unstable angina/non‐ST segment elevation myocardial infarction

Objectives: To determine the value of the TIMI risk score in the individual risk stratification of patients with unstable angina/non‐ST segment elevation myocardial infarction (UA/NSTEMI). Background: TIMI risk score is a validated tool to identify groups of patients at high risk for major cardiac events. Its prognostic value in individual patients with current diagnostic tools and therapy is unknown. Methods: TIMI risk score was assessed in patients with UA/NSTEMI admitted to six Belgian hospitals and related to clinical outcome at 30 days. Results: Of the 500 patients enrolled, 49.4% were placed in the low TIMI risk group (score = 0–3) and 50.6% in the high‐risk group (score = 4–7). Multivariate analysis identified raised cardiac markers and invasive strategy, but not high TIMI risk score as independent predictors of death and new myocardial infarction (MI). Moreover, the incidence of death and MI in the low TIMI risk group with positive cardiac markers was not lower than in the high TIMI risk group with positive markers: 15.1% versus 17.8% (P = 0.7). Conclusions: TIMI risk score is of limited value for individual risk stratification. The presence of positive cardiac markers (troponin) appears to be a more powerful prognostic marker.

Biventricular assist for severe acute rheumatic pancarditis

Severe heart failure in acute rheumatic myocarditis is rare. It may be rapidly reversible with treatment, so maximal medical treatment and, if necessary, mechanical support should be given before heart transplantation is considered.

Successful ablation of atrioventricular accessory pathway after cardiac transplantation

Liberalization of stringent guidelines regarding donor selection is acceptable in the case of critical recipient condition. Few cardiac allografts with preexisting accessory atrioventricular pathways have been implanted. We describe the successful radiofrequency modification of the atrioventricular node and ablation of an accessory pathway after cardiac transplantation. Although the previously healthy donor had no history of arrhythmia, the recipient’s postoperative course was characterized by multiple bouts of reentry tachycardia. The highly successful catheter-based ablation techniques available to cure this condition favor the use of donor hearts with a preexisting accessory pathway.

Letter by Vorlat et al Regarding Article, “Statins and the Risk of Cancer After Heart Transplantation”

We congratulate Frohlich et al for their article on the benefits of statins after heart transplantation.1 At a time when public opinion is alarmed by reports on statin use and the possible induction of cancer, their work is timely and reassuring. Nonetheless, issues remain to be solved and might have been addressed in the population that was actually studied by the researchers. From the ISHLT registry on adult heart transplantation it is known that freedom of …

Praktische aanbevelingen bij de aanpak van acute ritmestoornissen: Verslag van de Belgische Interdisciplinaire Werkgroep van Acute Cardiologie (BIWAC)

Acute arrhythmia is a condition covering a wide variety of rhythm disturbances. The aim of this article is to give practical recommendations for the management of the patient presenting with an acute arrhythmia. We discuss bradycardia and tachycardia. Tachycardias are divided into the small QRS complex tachycardias and the wide QRS complex tachycardias. Other important issues are the distinction between the hemodynamic stable and unstable patient and the need for trombo-embolic prevention of the patient with atrial fibrillation. Flowcharts with diagnostic means and therapeutic schemes as well as a table with practical considerations for electrical cardioversion are provided.