Federico Vallés

Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program.

Disease management programs can reduce hospitalizations in high‐risk heart failure (HF) patients, but generalizability to the population hospitalized for HF remains to be proven. We aimed to assess the effectiveness of a discharge and outpatient management program in a non‐selected cohort of patients hospitalized for HF.

Short- and long-term results of a programme for the prevention of readmissions and mortality in patients with heart failure : Are effects maintained after stopping the programme?

The objective of the study was to evaluate whether improvements obtained during an intervention programme were maintained after the programme was stopped. 153 patients discharged with a diagnosis of heart failure (HF) were randomized to either usual care or an intervention programme, which included patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit. After an average period of 16±8 months, the intervention programme was stopped. One year later, all the patients were re‐examined to assess HF readmissions, all‐cause mortality, quality of life, and prescribed medical treatment. During the 16±8‐month treatment period, patients in the intervention group had a lower rate of HF readmissions (17% vs. 51%, p<0.01), less all‐cause mortality (13% vs. 27%, p=0.03), improvement in quality of life (1.5±0.8 vs. 1.9±1, p=0.03) and optimisation of medical treatment was achieved. One year after stopping the intervention, there was no difference in HF readmissions (28% vs. 25%, p=0.72), all‐cause mortality (14% vs. 17%, p=0.64) and quality of life (1.7±0.9 vs. 1.8±1, p=0.24) between the groups. Survival and the probability of not being readmitted due to HF were similar in both groups. There was also a reduction in the use of beta‐blockers and spironolactone in the intervention group.

Clinical and hemodynamic predictors of survival in patients aged <65 years with severe congestive heart failure secondary to ischemic or nonischemic dilated cardiomyopathy

To identify which clinical or hemodynamic parameters predict survival in patients with end-stage heart failure due to dilated cardiomyopathy, 130 consecutive patients aged < 65 years (mean 46 +/- 13) assessed for heart transplantation from May 1986 to April 1991 were studied. Mean follow-up was 15 +/- 11 months. Left ventricular ejection fraction was 22 +/- 7%. Left ventricular end-diastolic pressure was 27 +/- 9 mm Hg, and cardiac index was 2.2 +/- 0.6 liter/min/m2. Symptom class was IV in 91% of patients and III in 9%. Etiology was ischemic in 40% of patients and idiopathic in 60%. After intensive medical therapy, heart transplantation was considered indicated in 53% of patients, contraindicated in 20% and not indicated in 27%. Transplantation was performed in 36% of patients during follow-up, and 35% died and 29% were alive without transplantation. A comparison, excluding patients with transplantation, was performed between those who were alive and had survived > or = 6 months after assessment, and those who died. On multivariate analysis, the following 3 parameters were independent predictors of prognosis: intravenous inotropic requirement (p < 0.001), maximal, tolerated captopril dose (p = 0.013) and systolic blood pressure (p = 0.003). When patients with transplantation were considered as deaths, stabilization on medical therapy also reached statistical significance (p = 0.009). Classic prognostic markers including ventricular arrhythmias, left ventricular end-diastolic pressure, cardiac index, amiodarone therapy and etiology were not associated with prognosis in this homogeneous population of severely ill patients.

Percutaneous transluminal balloon dilatation for discrete subaortic stenosis.

Seven patients, mean age 8 +/- 3.6 years, with clinical and hemodynamic diagnoses of discrete subaortic stenosis were treated by percutaneous transluminal balloon dilatation (PTBD) of the membrane during cardiac catheterization. One patient had an associated aortic coarctation that was first dilated. After PTBD left ventricular (LV) systolic pressure decreased significantly, from 181 +/- 25 to 139 +/- 11 mm Hg (p less than 0.005); peak gradient diminished from 65 +/- 18 to 12 +/- 9 mm Hg (p less than 0.001). Mild aortic regurgitation was present in 6 patients during basal conditions. After PTBD, the same degree of regurgitation was observed in all but 1 patient, in whom it disappeared. There were no major complications. Clinical observations after PTBD were consistent with hemodynamic findings. Precordial thrill always disappeared and the peak murmur became earlier in systole. In 2 patients the discrete subaortic stenosis was clearly visualized at 2-dimensional echocardiography as a fixed subvalvular structure throughout the cardiac cycle. After dilatation this was only identifiable at its implantation base; during contraction there was no fixed structure at the LV outflow tract. Four patients were hemodynamically reevaluated 6.7 +/- 1.7 months later and were found to have LV pressure relief and a degree of aortic regurgitation similar to those observed immediately after PTBD.

Características clínicas y pronóstico a medio plazo de la insuficiencia cardíaca con función sistólica conservada. ¿Es diferente de la insuficiencia cardíaca sistólica?

Objetivos Analizar la prevalencia, las caracteristicas clinicas y el pronostico a medio plazo de los pacientes con insuficiencia cardiaca y funcion sistolica conservada, y compararlos con los que presentan disfuncion ventricular. Pacientes y metodo Se incluyo a un total de 153 pacientes, 62 con funcion sistolica conservada (fraccion de eyeccion ventricular izquierda ≥ 45%) y 91 con disfuncion ventricular (fraccion de eyeccion Resultados Las edades medias fueron similares (66 ± 10 frente a 65 ± 10 anos; p = 0,54). La proporcion de mujeres fue mayor entre los pacientes con funcion sistolica conservada (53 frente a 28%; p Conclusiones Una importante proporcion de pacientes con insuficiencia cardiaca presentan una funcion ventricular sistolica conservada. Aunque las caracteristicas clinicas de estos pacientes son distintas de las de aquellos con disfuncion ventricular sistolica, el pronostico a medio plazo fue similar.

Guías de práctica clínica de la Sociedad Española de Cardiología en endocarditis

La endocarditis infecciosa es una enfermedad que afecta, fundamentalmente, a las valvulas cardiacas, con mal pronostico y que es originada por gran variedad de microorganismos. La profilaxis es muy importante, pero hay muchos interrogantes sobre su verdadera efectividad y la mejor forma de llevarla a cabo. En este articulo se presentan unas recomendaciones en este sentido. El diagnostico se basa en hallazgos clinicos, bacteriologicos y ecocardiograficos, fundamentalmente siguiendo los criterios de Duke. Los ecocardiogramas transtoracico y transesofagico tienen no solo valor diagnostico, sino que son una buena guia para decidir la actitud terapeutica. El tratamiento antibiotico se basa en los hallazgos del hemocultivo, si bien se presentan pautas no solo especificas para los diferentes germenes hallados, sino tambien en caso de hemocultivos negativos. Por ultimo se valoran las indicaciones y el momento adecuado de la cirugia.

Comparison of Bezafibrate Versus Lovastatin or Lowering Plasma Insulin, Fibrinogen, and Plasminogen Activator Inhibitor-1 Concentrations in Hyperlipemic Heart Transplant Patients

Accelerated coronary artery disease is the most serious obstacle to long-term survival in heart transplant recipients. Hyperlipemia, hyperinsulinism, and changes in endothelial cell hemostatic function have been implicated in cardiac allograft vascular disease. Both lovastatin and bezafibrate are safe, effective, and well tolerated therapies for hyperlipidemia. Our study compares the effect of these lipid-lowering drugs in 21 patients with post-heart transplantation hyperlipidemia on different risk factors related to insulin resistance syndrome. Patients were given the same diet for 3 months, then randomized to lovastatin or bezafibrate for a period of 8 weeks, and crossed over to an additional 8 weeks of either bezafibrate or lovastatin. Baseline parameters were also compared with those of a control group of healthy subjects and after both periods of pharmacologic treatment. Transplant patients had higher insulin (35 +/- 3 vs 24 +/- 3 microIU/L), fibrinogen (298 +/- 15 vs 261 +/- 14 mg/dl), and plasminogen activator inhibitor-1 (PAI-1) (17 +/- 2 vs 11.7 +/- 2 arbitrary units/ml) plasma levels than controls. Significant decreases in insulin (-37 +/- 3%), fibrinogen (-12 +/- 4%), and PAI-1 plasma levels (-18 +/- 12%) were only observed after bezafibrate treatment. In conclusion, bezafibrate decreases plasma insulin, fibrinogen, and PAI-1 in hyperlipidemic heart transplant recipients.

The activation antigen CD69 is selectively expressed on CD8+ endomyocardium infiltrating T lymphocytes in human rejecting heart allografts

We analyzed the presence of T-cell subsets (CD4/CD8) and the activation markers CD25 and CD69 in the cellular infiltrates of endomyocardium biopsies taken from transplanted human hearts. The results indicate that CD25 was present within specimens mainly infiltrated by CD4+ cells. In contrast, CD69 was found in infiltrated biopsies by CD8+ cells, as determined by single immunofluorescence. Double immunoenzymatic staining was used to investigate the cellular distribution of the activation markers studied in some representative cases. Thus, CD25 was found on both CD4+ and CD8+ cells while CD69 molecule was selectively expressed on CD8+ T-cell subset. These results suggest that CD69 is a surface molecule relevant to the CD8+ cell-mediated graft rejection events of allografted human hearts.

Factores de riesgo asociados a endocarditis sin cardiopatía predisponente

La patogenia de la endocarditis infecciosa (EI) ha cambiado en las ultimas decadas, siendo cada vez mayor el numero de casos sin cardiopatia predisponente. El objetivo de este trabajo es conocer las caracteristicas de los pacientes no drogadictos afectados de EI sin cardiopatia predisponente e identificar los posibles factores de riesgo para la infeccion. De 196 casos de EI, 49 (25%) ocurrieron en pacientes sin cardiopatia predisponente. Se identifico en la mayoria (26 casos) un factor de riesgo para la infeccion, predominando las enfermedades digestivas (6 casos), hemodialisis (6 casos) y cateteres venosos centrales (4 casos). La infeccion se localizo con mayor frecuencia en las valvulas derechas (29 frente a 6%; p

Factors influencing progression of mitral regurgitation after transarterial balloon valvuloplasty for mitral stenosis

This study analyzes the clinical, echocardiographic and hemodynamic factors affecting progression of mitral regurgitation (MR) after transarterial balloon valvuloplasty in 200 consecutive patients with rheumatic mitral stenosis. After valvuloplasty, the mitral valve area increased in all patients, from 1.03 +/- 0.36 to 2.06 +/- 0.71 cm2 (p less than 0.0001). With regard to the basal stage, the mitral valve was competent in 139 patients and there was mild MR in 61 (grade I in 53, and grade II in 8). Three patients had progression of MR induced by a technical deficiency and they were excluded from analysis. Patients were classified into 2 groups on the basis of the degree of MR before and after valvuloplasty: group A--no progression of MR (n = 167; 85%) when the degree of MR did not change, disappeared after valvuloplasty, or increased from grade 0 to I; group B--progression of MR (n = 30; 15%) when the degree of MR increased to greater than or equal to grade II. Progression of MR was observed more frequently in older patients with presence of chronic atrial fibrillation, larger left atrial size and left ventricular volumes, baseline MR, more severe stenosis and a lower ejection fraction. Multivariate analysis selected age, left ventricular volumes and ejection fraction as independent predictors of progression of MR. All these factors suggest that progression of MR after balloon valvuloplasty could be related to a more advanced degree of disease.