E Saura

Acute myocardial infarction with cardiogenic shock: treatment with mechanical circulatory assistance and heart transplantation

UNLABELLED The mortality of cardiogenic shock (CS) after an acute myocardial infarction (AMI) still remains high. Thrombolysis, PTCA or CABG, when possible, can improve the results, but when all the treatments fail death is almost certain. OBJECTIVE We investigate the use of the mechanical circulatory assistance (MCA) and heart transplantation (HT) to improve the adverse results in this irreversible situation. METHODS Among 11 patients with irreversible CS after an AMI we used a MCA (Abiomed BVS-5000). After improvement and hemodynamic stabilization, we performed heart transplantation in 7 patients of mean age 52 years (35-60) including two women. The MCA was univentricular in 7 patients and biventricular in 4. Mean duration of the MCA was 5 days (1-12). RESULTS Three patients died during the MCA: two due to cerebrovascular accidents and one multiorgan failure. Weaning was possible in one patient. Among Seven transplanted patients one died due to sepsis. Seven (64%) patients are long-term survivors. CONCLUSION When all the treatments have failed for CS after an AMI, MCA may be used as a bridge to heart transplantation in a select group of patients where the procedure is not contraindicated. The long-term results of 64% survivors in our experience is satisfactory.

Heart transplant recipient clinical profile improvement following mycophenolate mofetil late incorporation into the treatment schedule

Abstract:  Mycophenolate mofetil (MMF) has a better clinical profile than azathioprine in heart transplantation (HT). Forty‐five recipients (aged 53 ± 9 yr) were retrospectively evaluated (first year of follow‐up) post‐MMF introduction since its advent in 1997 (mean daily dose: 1.97 ± 0.2 g). MMF was used (mean post‐HT time: 40 ± 27 months) for: (i) renal insufficiency attenuation (group 1 = 20); (ii) steroid reduction because of osteoporosis (group 2 = 12); (iii) treatment of persistent cellular rejection (group 3 = 7) and vascular graft disease (VGD) (group 4 = 6). Mean changes (groups 1–2) were: creatinine 172 ± 59, 158 ± 51, 153 ± 57 μmol/L (at baseline, 6 and 12 months, respectively; p < 0.001). Cyclosporine daily dose: 219 ± 37, 166 ± 46, 176 ± 98 mg, respectively (p < 0.001). Cyclosporine blood concentration: 151 ± 40, 103 ± 41, 83 ± 34 ng/mL, respectively (p < 0.004). Prednisone daily dose: 8.3 ± 2, 5.2 ± 1, 4.1 ± 1 mg, respectively (p < 0.001). Cellular rejection (group 3) was successfully treated (86%) but the outcome of VGD did not improve after the switch (group 4). Our limited experience (with caution) confirms the reported benefits of MMF particularly attenuating renal insufficiency.

Mitral Annuloplasty with the Puig Massana-Shiley Ring: Long-Term Results

The use of mitral annuloplasties is increasing. Since 1977 we have employed an original flexible and adjustable ring to increase the reliability of such operations. A total of 314 rings were implanted until 1986, 237 in the mitral valve and 77 in the tricuspid valve.

Ventricular Circulatory Support with the Abiomed System as a Bridge to Heart Transplantation

The Abiomed system was initially designed as a mechanical support for postcardiotomy failure, but it has been also used as a bridge to heart transplantation. We review our experience with this system since November 1992 in 10 patients. The mean age was 46 years. Nine were men. The underlying cardiac disease was ischemic cardiomyopathy in 8, dilated cardiomyopathy in 1, and acute myocarditis in 1. The cardiogenic shock was due to an acute myocardial infarction in 7 (one after coronary bypass and another with a left ventricular rupture), end-stage cardiac insufficiency in 2 (already on the heart transplantation waiting list), and early graft failure in 1. The implantation of the system was performed without extracorporeal circulation. The type of support was biventricular in 4 and left ventricular in 6. The hemodynamic improvement was important in terms of the vital constants and cardiac output. The mean flow of the right pump was 4.61/min and that of the left pump, 4.41/min. Three (30%) died under mechanical support for a mean of 7 days, six (60%) were successfully transplanted after a mean of 3.5 days, and one (10%) was able to be weaned 7 days later. Only one (10%) died, after 2 months because of sepsis. All survivors (60%) are asymptomatic. Bleeding (50%) and thromboembolism (40%) were the most frequent complications. The Abiomed system proved to be useful in the recovery from cardiogenic shock, especially after acute myocardial infarction. It can be managed simply and the cost is limited. Of our supported patients, 60% are long-term survivors. This system can also be used as a bridge of short duration to heart transplantation.