J.F. Delgado Jiménez

Spontaneous left atrial haematoma

We present a woman with paroxysmal atrial fibrillation and a mass in the left atrium. Cross-sectional echocardiography defined the lesion as cystic, while magnetic resonance imaging depicted it as a solid mass with areas of focal bleeding. Surgical resection showed a partially organized haematoma within the left atrial wall. The patient did well after surgery, although atrial fibrillation recurred. The presence of an atrial haematoma is rare, specially when spontaneous, and we stress the usefulness of magnetic resonance in reaching an aetiologic diagnosis.

Effect of Different Pharmacologic Agents to Reverse Severe Pulmonary Hypertension Among End-Stage Heart Failure Patients

OBJECTIVE The goal of this study was to analyze the hemodynamic responses during vasoreactivity tests among candidates for heart transplantation who displayed severe pulmonary hypertension seeking to identify risk markers of nonresponse to the test. MATERIALS AND METHODS In this observational retrospective study we evaluated demographic, clinical, echocardiographic, and hemodynamic variables. The target hemodynamic goal in the vasoreactivity test was to achieve a transpulmonary gradient (TPG) <12 mm Hg and/or pulmonary vascular resistances (PVR) <2.5 Wood Units (WU). RESULTS We analyzed medical records from 79 patients. Inotropes (dopamine or dobutamine) were used to treat 33 patients, nonselective vasodilators (nitroglycerin or sodium nitroprusside) were used in 22 patients, and prostacyclin (PC) was used in 24 patients. The study observed a significant decrease in pulmonary pressures, PVR, and TPG, with increased cardiac output (CO) compared with baseline hemodynamics in all groups. No significant differences were observed between agents except for an increase in CO, which was greater in the PC group. Also, 49.4% of patients were considered responders to the vasoreactivity test without significant differences between groups. Risk markers for absence of a response to the vasoreactivity test were a CO <2.5 L/min (odds ratio [OR] = 2.1; confidence interval [CI] 95%, 1.1-3.9; P = .035) and a PVR >6 WU (OR = 3.7; CI 95%, 1.8-7.6; P < .001) in the baseline hemodynamic study. CONCLUSIONS Inotropes, nonselective vasodilators, and prostacyclin produced effective vasodilator responses in the pulmonary vascular bed during the vasoreactivity test. The presence of a baseline high PVR or a low CO were predictors of nonresponse to the test.

Steroid Withdrawal During 5 Years Following Heart Transplantation, and the Relationship Between Steroid Dosage at 1-Year Follow-up and Complications During the Next 2 Years: Results From the RESTCO Study

BACKGROUND Little information is available regarding the controversial issue of steroid withdrawal following heart transplantation (HT), or instead in the incidence of adverse steroid effects at dosages typically employed in Spain. METHODS We analyzed the 5-year follow-up records of 1209 patients (82.5% men, aged ≥ 18 years) who underwent HT between 2000 and 2005 and survived at least 1 month in 13 Spanish centers. The incidences of first steroid withdrawal before 1, 3, and 5 years post-HT were expressed as Kaplan-Meier probability estimates. Three patient groups defined in accordance with steroid dosage at 1-year follow-up (0, ≤ 5, and >5 mg/d; groups A, B, and C, respectively) were compared with regard to the incidence of de novo hypertension, diabetes, and bone fractures over the following 2 years. RESULTS The 5-year incidence of withdrawal was 28%, 21% of whom required reintroduction of steroids. Kaplan-Meier probabilities of withdrawal before 1, 3, and 5 years post-HT were 8.8% (95% confidence interval ([CI] 7.3%-10.7%), 27.8% (CI 25.2%-30.6%), and 30.2% (CI 27.5%-33.2%), respectively. At 1-year follow-up, 9.9% of patients were steroid-free, 28.9% were taking ≤ 5 mg/d, and 61.3% >5 mg/d. The 2-year incidence of de novo hypertension increased significantly (P = .012) from 13.5% to 29.6% to 35.3% in groups A, B, and C respectively. These groups did not differ significantly in regard to the 2-year incidence of diabetes or bone fractures. CONCLUSIONS Reintroduction of steroids was required by 21% of the 28% of Spanish HT patients who has been weaned from steroids within 5 years of HT. The incidence of de novo hypertension between 1 and 3 years post-HT increased with steroid dosage at 1-year follow-up. De novo diabetes and bone fractures showed no similar significant association.

Influence of Steroid Dosage, Withdrawal, and Reinstatement on Survival After Heart Transplantation: Results From the RESTCO Study

BACKGROUND Little information is available regarding the consequences of steroid withdrawal following heart transplantation (HT) in Spain. METHODS We analyzed the records of 1068 patients (81.6% men) who underwent HT between 2000 and 2005 in 13 Spanish centers who were aged ≥ 18 years and who survived at least 1 year. Death rates and Kaplan-Meier survival curves for 1 to 5 years post-HT were compared among four groups: groups A and B, patients on steroids throughout the first 5 years post-HT at dosages of ≤ 5 mg/d between 1-year and 5-year follow-up (group A; n = 148), or >5 mg/d for some part of this period (group B; n = 578). Groups C and D were patients from whom steroids were at some point withdrawn including group D (n = 73) with and group C (n = 269) without subsequent reintroduction into the maintenance regimen. RESULTS Steroids were withdrawn at 1.6 ± 0.9 years post-HT in group C, and 1.7 ± 1.2 years post-HT in group D. The death rate between 1- and 5-year follow-up (deaths per 1000 person-years) was 44.3% (95% confidence interval 26.2-62.5) in group A, 42.6% (33.7-51.4) in group B, 30.5% (19.6-41.4) in group C, and 47.8% (21.8-73.7) in group D. There was no significant difference among them or among Kaplan-Meier survival curves of the four groups (P = .34 in both cases). Comparison of combined groups C + D with groups A + B showed no evidence of a greater mortality among combined groups C + D. CONCLUSIONS The late withdrawal of steroids following HT was not associated with increased mortality.

Sildenafilo como sustituto de prostaciclina subcutánea en la hipertensión pulmonar

La prostaciclina subcutanea (treprostinil) es efectiva a corto plazo para el tratamiento de la hipertension pulmonar. El efecto adverso descrito con mas frecuencia es el dolor sobre la zona de infusion, que en raras ocasiones obliga a suspender el tratamiento. El sildenafilo es un inhibidor selectivo de la fosfodiesterasa-5 con efecto vasodilatador pulmonar. Describimos el cambio de treprostinil por sildenafilo en una paciente con hipertension pulmonar asociada a lupus eritematoso, a quien se le retiro el treprostinil debido a dolor abdominal incontrolable