Enrique Rodríguez

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.

Three-dimensional echocardiography in paravalvular aortic regurgitation assessment after transcatheter aortic valve implantation.

BACKGROUND Paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is common, but the evaluation of its severity by two-dimensional (2D) transthoracic echocardiography (TTE) presents several constrains. The aim of this study was to assess the usefulness of a new methodology, using three-dimensional (3D) TTE, for better assessment of paravalvular AR after TAVI. METHODS Two-dimensional and 3D TTE was performed in 72 patients, 5 months after TAVI, using the X5-1 PureWave microbeamforming xMATRIX probe. The position and severity of the paravalvular AR jets were described using 2D and 3D TTE, and a model was designed for paravalvular AR systematic location description. Vena contracta width was measured using 2D transthoracic echocardiographic views, and the planimetry of the vena contracta was assessed after the perfect alignment plane was obtained using the multiplanar 3D transthoracic echocardiographic reconstruction tool. AR volume was calculated as the difference between 3D TTE-derived total left ventricular stroke volume and right ventricular stroke volume estimated using 2D TTE. Diagnostic efficiency for moderate AR was assessed using receiver operating characteristic curve analysis. RESULTS Forty-three patients (57.4%) presented with AR; 10 (13.3%) had central AR, and 33 (44.0%) had paravalvular AR jets. Vena contracta widths were similar between patients with moderate and mild AR (2.1 ± 0.53 vs 1.9 ± 0.16 mm, P = .16), but vena contracta planimetry was larger in patients with moderate AR than in those with mild AR (0.30 ± 0.12 vs 0.09 ± 0.07 cm(2), P = .001). Vena contracta planimetry on 3D TTE was better correlated with AR volume than vena contracta width on 2D TTE (Kendalls τ = 0.82 [P < .001] vs 0.66 [P < .001]). The areas under the receiver operating characteristic curves were 0.96 for vena contracta planimetry and 0.35 for vena contracta width. CONCLUSIONS This study proposes an alternative methodology for paravalvular AR assessment after TAVI. Using vena contracta planimetry on 3D TTE, an accurate methodology for paravalvular AR jet evaluation and moderate AR classification is described.

Acute Coronary Syndrome in Infective Endocarditis

INTRODUCTION AND OBJECTIVES To describe the clinical, microbiologic, echocardiographic characteristics, and disease progression in patients who experience an acute coronary syndrome during an episode of endocarditis. METHODS The study included 586 consecutive patients who were diagnosed of infective endocarditis (481 left-sided) at one of five hospitals between 1995 and 2005. RESULTS Overall, 14 patients (2.9%) had an acute coronary syndrome. Their mean age was 50 (17) years, and 50% had a prosthetic valve. For 11 episodes of endocarditis, laboratory cultures tested positive, with Staphylococcus aureus being the most frequently isolated microorganism. Vegetations were detected by transesophageal echography in 12 cases. The infection was located in the aortic valve in 12 cases. In the 14 patients, periannular complications were found more frequently (11 [78.6%] vs 172 [36.8%]; P=.03), and their size was greater than in other patients. Thirteen had moderate-to-severe valvular regurgitation. In most patients, acute coronary syndrome was an early complication of endocarditis. Myocardial ischemia was due to an embolism in three cases and to coronary artery compression in eight. During follow-up, patients with acute coronary syndrome had higher incidences of heart failure (6 [42.85%] vs 77 [16.48%]; P=.021), cardiogenic shock (5 [35.7%] vs 71 [15.2%]; P=.038), complete atrioventricular block (4 [28.57%] vs 43 [9.2%]; P=.039), and mortality (9 [64.29%] vs 151 [32.33%]; P=.019). CONCLUSIONS Acute coronary syndrome is usually an early complication of infective endocarditis. It is associated with virulent microorganisms, aortic valve infection, severe valvular regurgitation, extensive periannular complications, and increased mortality. The most frequent cause of myocardial ischemia was coronary artery compression secondary to periannular complications.

Effect of clopidogrel on the expression of inflammatory markers in rabbit ischemic coronary artery

Inflammation and platelet activation are critical phenomena in the setting of acute coronary syndromes. Platelets may contribute to increase ischemic injury by enhancing the inflammatory response of leukocytes and endothelial myocardial cells. Pharmacological inhibition of platelet activation prevents ischemic complications in patients with coronary diseases. Agents directed against the integrin glycoprotein IIb/IIIa (GP IIb/IIIa) receptor not only inhibit platelet aggregation but also have been demonstrated to limit the inflammatory response in acute coronary syndromes. The question then raised is if the inhibition of platelet activation by other mechanisms than the blockade of GP IIb/IIIa may also exert anti‐inflammatory effects. The aim of the present study was to analyze if clopidogrel may exert anti‐inflammatory effects during the acute phase of myocardial infarction. A ligature was placed around the left anterior descending coronary artery of New Zealand White rabbits. After 15 min of ischemia, the myocardium was reperfused and the ischemic coronary artery was isolated 24 h after the ischemia. A group of ischemic rabbits was given a single oral dose of clopidogrel (20 mg kg−1) just after the arterial occlusion and the animal was recovered. Sham‐operated animals served as control. P‐selectin expression was significantly increased in infarcted rabbits with respect to control rabbits. Clopidogrel administration reduced P‐selectin expression with respect to untreated infarcted rabbits. CD40 ligand and tissue factor expression was increased in the ischemic coronary artery and reduced after clopidogrel administration. Clopidogrel also protected endothelial nitric oxide synthase protein expression in the ischemic coronary artery, a protein that has been found downregulated under inflammatory conditions. In conclusion, inhibition of platelet activation by clopidogrel exerted anti‐inflammatory effects on the ischemic coronary artery.

Acute aortic syndrome: a new look at an old conundrum

The term acute aortic syndrome (AAS), coined several years ago, is now widely recognised. In the light of new findings in aortic pathology and in an era when modern imaging techniques are widely available and interventional management of AAS is increasing, some morphological and diagnostic aspects of acute aortic pathology have been examined and the syndrome updated. This article provides a new, comprehensive overview of the pathology, diagnosis, evolution and management of patients with AAS. As acute aortic disease is the most common fatal condition in patients with chest pain, prompt recognition and treatment is of paramount importance.The term acute aortic syndrome (AAS), coined several years ago, is now widely recognised. In the light of new findings in aortic pathology and in an era when modern imaging techniques are widely available and interventional management of AAS is increasing, some morphological and diagnostic aspects of acute aortic pathology have been examined and the syndrome updated. This article provides a new, comprehensive overview of the pathology, diagnosis, evolution and management of patients with AAS. As acute aortic disease is the most common fatal condition in patients with chest pain, prompt recognition and treatment is of paramount importance.

Chronic mitral regurgitation: a pilot study to assess preoperative left ventricular contractile function using speckle-tracking echocardiography.

BACKGROUND The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral regurgitation (MR) and implies a poor prognosis. The aim of this study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional echocardiography-based speckle-tracking analysis in patients with chronic severe MR. METHODS Thirty-eight consecutive patients with chronic severe MR scheduled for mitral valve replacement were prospectively enrolled. Preoperative two-dimensional echocardiography-based speckle-tracking analysis at the level of the interventricular septum (IVS) was carried out, and strain and strain rate values were obtained. LV dP/dt and Doppler tissue imaging-derived strain and strain rate measurements were also obtained. LV volumes and LV ejection fraction (LVEF) were defined using three-dimensional echocardiography. RESULTS Preoperative speckle tracking-derived longitudinal strain and strain rate values at the level of the IVS strongly predicted a postoperative LVEF decrease of >10%. Their predictive values were greater than those obtained for preoperative LV volumes and LVEF, LV dP/dt, and Doppler tissue imaging-derived strain and strain rate. The best discriminant parameter to detect a postoperative LVEF reduction of >10% with speckle tracking was a longitudinal strain rate at the level of the mid IVS < -0.80 s(-1) (area under the receiver operating characteristic curve, 0.88; sensitivity, 60%; specificity, 96.5%; positive predictive value, 90%; negative predictive value, 82.35%). CONCLUSIONS IVS longitudinal speckle tracking-derived strain rate allows the accurate detection of early abnormalities in LV contractile function. It is a powerful predictor of early postoperative LVEF decreases in patients with chronic severe MR. Furthermore, speckle-tracking technology is more accurate than other methods. This new tool might assist clinicians in the optimal timing of surgery in patients with chronic severe MR.

Síndrome coronario agudo en la endocarditis infecciosa

Introduccion y objetivos Describir las caracteristicas epidemiologicas, clinicas, microbiologicas, ecocardiograficas y evolutivas de los pacientes con un sindrome coronario agudo en el seno de una endocarditis. Metodos Hemos analizado 586 episodios de endocarditis (481 izquierdos) diagnosticados de forma consecutiva en 5 hospitales desde 1995 hasta 2005. Resultados Hubo 14 pacientes (2,9%) con un sindrome coronario agudo, con una edad media de 50 ± 17 anos. El 50% tenian una protesis valvular. Los cultivos fueron positivos en 11 episodios y el germen aislado con mas frecuencia fue Staphylococcus aureus. La ecocardiografia transesofagica detecto vegetaciones en 12 casos. La localizacion de la infeccion fue aortica en 12 casos. Se documentaron con mas frecuencia complicaciones perivalvulares (n = 11 [78,6%] frente a n = 172 [36,8%]; p = 0,03) y su tamano fue mayor que el de los otros pacientes de la serie. Trece pacientes tuvieron insuficiencia valvular de moderada a severa. El sindrome coronario agudo se manifesto precozmente en la mayoria de los pacientes. El mecanismo de la isquemia fue embolico en 3 casos y por compresion coronaria en 8. Durante la evolucion, los pacientes con sindrome coronario agudo tuvieron una mayor incidencia de insuficiencia cardiaca (n = 6 [42,85%] frente a n = 77 [16,48%]; p = 0,021), shock cardiogenico (n = 5 [35,7%] frente a n = 71 [15,2%]; p = 0,038) y bloqueo auriculoventricular (n = 4 [28,57%] frente a 43 [9,2%]; p = 0,039). La mortalidad fue tambien superior en estos pacientes (n = 9 [64,29%] frente a n = 151 [32,33%]; p = 0,019). Conclusiones El sindrome coronario agudo es una complicacion precoz de la endocarditis. Se asocia mas a microorganismos virulentos, infeccion valvular aortica, insuficiencia valvular severa, complicaciones perianulares de gran tamano y elevada mortalidad. El mecanismo mas frecuente fue la compresion coronaria secundaria a complicaciones perianulares.

Acute left ventricle diastolic function improvement after transcatheter aortic valve implantation

AIMS Data regarding the effects of TAVI on LV after are scarce and conflicting results have been reported immediately after aortic valvuloplasty. This study aimed to determine the acute haemodynamic effects of transcatheter aortic valve implantation (TAVI) in left ventricle (LV) diastolic performance, immediately after aortic valvuloplasty and prosthesis deployment. METHODS AND RESULTS Sixty-one patients with severe aortic valve stenosis, and preserved LV systolic function submitted to successful TAVI, were included. All procedures were guided through transoesophageal echocardiography, and parameters of diastolic function were evaluated before and minutes after TAVI. The mean age was 83.5±6 years and mean log EuroSCORE was 18.2±9.4. Before the procedure, all patients presented LV diastolic dysfunction. Immediately after TAVI, fewer patients presented a restrictive pattern [27 (44.3%), before the procedure, vs. 20 (34.4%), after TAVI (P=0.047)], and an increase in E wave deceleration time (211.2±75.5 vs. 252.7±102.3 cm/s, P=0.001), in E wave velocity (109.5±41.2 vs. 120.3±43.6 cm/s, P=0.025), and in isovolumetric relaxation time (83±36.5 vs. 97.1±36.0 ms, P=0.013) was observed. On multivariate analysis of covariance (ANCOVA), adjusting to LV systolic function, heart rate, blood pressure, and haematocrit values, the results remained significant. Patients referred to percutaneous approach had invasive haemodynamic data collected, showing a decrease in LV end-diastolic pressure after valve implantation [18.8±5.7 vs. 14.7±4.7, mean difference -4.1 (95% CI: -5.9; -2.9)]. Patients with a restrictive pattern immediately after TAVI presented a smaller decrease in LV end diastolic pressure (-3.3±4.7) than those with diastolic dysfunction grade I or II (-9.5±4.7; P=0.017). CONCLUSION This is the first study describing LV diastolic performance during TAVI. Our results show improvement in diastolic function parameters in patients with preserved LV systolic function, immediately after successful TAVI.

Rationale, design, and methods for the early surgery in infective endocarditis study (ENDOVAL 1): A multicenter, prospective, randomized trial comparing the state-of-the-art therapeutic strategy versus early surgery strategy in infective endocarditis

BACKGROUND The prognosis of infective endocarditis is poor and has remained steady over the last 4 decades. Several nonrandomized studies suggest that early surgery could improve prognosis. METHODS ENDOVAL 1 is a multicenter, prospective, randomized study designed to compare the state-of-the-art therapeutic strategy (advised by the international societies in their guidelines) with the early-surgery strategy in high-risk patients with infective endocarditis. Patients with infective endocarditis without indication for surgery will be included if they meet at least one of the following: (1) early-onset prosthetic endocarditis; (2) Staphylococcus aureus endocarditis; (3) periannular complications; (4) new-onset conduction abnormalities; (5) new-onset severe valvular dysfunction. A total of 216 patients will be randomized to either of the 2 strategies. Stratification will be done within 3 days of admission. In the early surgery arm, the surgical procedure will be performed within 48 hours of randomization. The only event to be considered will be death within 30 days. The study will be extended to 1 year. In the follow-up substudy, death and a new episode of endocarditis will be regarded as events. CONCLUSION ENDOVAL 1, the first randomized study on endocarditis, will provide crucial information regarding the putative benefit of early surgery over the state-of-the-art therapeutic approach in high-risk patients with infective endocarditis.

Nitric oxide inhibits Kv4.3 and human cardiac transient outward potassium current (Ito1).

AIMS Chronic atrial fibrillation (CAF) is characterized by a shortening of the plateau phase of the action potentials (AP) and a decrease in the bioavailability of nitric oxide (NO). In this study, we analysed the effects of NO on Kv4.3 (I(Kv4.3)) and on human transient outward K(+) (I(to1)) currents as well as the signalling pathways responsible for them. We also analysed the expression of NO synthase 3 (NOS3) in patients with CAF. METHODS AND RESULTS I(Kv4.3) and I(to1) currents were recorded in Chinese hamster ovary cells and in human atrial and mouse ventricular dissociated myocytes using the whole-cell patch clamp. The expression of NOS3 was analysed by western blotting. AP were recorded using conventional microelectrode techniques in mouse atrial preparations. NO and NO donors inhibited I(Kv4.3) and human I(to1) in a concentration- and voltage-dependent manner (IC(50) for NO: 375.0 +/- 48 nM) as a consequence of the activation of adenylate cyclase and the subsequent activation of the cAMP-dependent protein kinase and the serine-threonine phosphatase 2A. The density of the I(to1) recorded in ventricular myocytes from wild-type (WT) and NOS3-deficient mice (NOS3(-/-)) was not significantly different. Furthermore, the duration of atrial AP repolarization in WT and NOS3(-/-) mice was not different. The increase in NO levels to 200 nM prolonged the plateau phase of the mouse atrial AP and lengthened the AP duration measured at 20 and 50% of repolarization of the human atrial CAF-remodelled AP as determined using a mathematical model. However, the expression of NOS3 was not modified in left atrial appendages from CAF patients. CONCLUSION Our results suggested that the increase in the atrial NO bioavailability could partially restore the duration of the plateau phase of CAF-remodelled AP by inhibiting the I(to1) as a result of the activation of non-canonical enzymatic pathways.