Jesús Herreros

Skin cancer in heart transplant recipients

BACKGROUND The frequency of skin cancer in organ transplant recipients is high, up to 15%. OBJECTIVE Our purpose was to determine the incidence of skin cancer in patients who underwent immunosuppression after heart transplantation and to determine the factors important in the appearance of skin cancer. METHODS We studied the frequency of skin cancer in 92 of 111 patients after they underwent heart transplantation between January 1984 and December 1993. RESULTS At least one cutaneous neoplasm (squamous cell carcinoma and/or basal cell carcinoma) developed in 14 patients (15.2%). The basal cell carcinoma to squamous cell carcinoma ratio was 1:1.5. The skin cancer appeared an average of 31.5 months after transplantation; the average was 36 months for squamous cell carcinoma and 25.3 months for basal cell carcinoma. Cumulative risk rose from 4.3% at 1 year up to 43.8% at 7 years after transplantation. The overall incidence of both types of skin cancer was 45.3 per 1000 posttransplant person-years, with an incidence of 25.8 for basal cell carcinoma and 29.1 for squamous cell carcinoma. Most skin cancers developed between 2 and 3 years after transplantation. All patients were exposed to a significant amount of ultraviolet radiation and had skin type II or III. We did not find a significant association between skin cancer and haplotype HLA-A3, HLA-A11, HLA-DR, and the number of mismatches for HLA-B. CONCLUSION We found an increased progressive cumulative incidence of skin cancer in heart transplant recipients for two reasons: (1) immunosuppression and increased exposure to ultraviolet radiation in some patients, and (2) the skin type of certain patients. We emphasize the need for photoprotection in this group of patients and regular skin cancer screening examinations.

Combined treatment in superior sulcus tumors

January 1988 to August 1992, 18 patients (pts) with the established diagnosis of non-small cell lung cancer of the superior sulcus have been treated with a multidisciplinary approach, which includes 1–3 cycles of neoadjuvant chemotherapy (MVP or MCP regimens) followed by simultaneous preoperative chemotherapy and external beam irradiation. Radical surgery plus intraoperativc radiotherapy (IORT) was planned 4–5 weeks after the end of the preoperative protocol. Tumor stages were IIIA (9 pts) and IIIB (9 pts). Tumor characteristics included rib and vertebral involvement in 15 and 4 pts, respectively. Fatal toxicity was present in 3 pts (16.6%). Resectability rate was 76.4%. Pathologic findings disclosed complete response (pT0) in 70.5% of the surgical specimens and viable tumor (pT+) in 29.5%. With a median follow-up of 24+ months (2–52+), 4-year actuarial local control, and overall survival rates are 91% and 56.2%, respectively. Four-year actuarial overall survival according to pathologic response was 87.5% for pT0 patients and 20% for pT + patients. We conclude that this regimen promotes a high rate of pT0 as well as better than expected local control and survival rates. The presence of a pT0 specimen seems to correlate with the patient outcome.

Treatment of Heart Failure with Autologous Skeletal Myoblasts

Background: The management of patients with heart failure is a daily challenge for cardiologists and cardiac surgeons. Pharmacotherapy, atrio-biventricular resynchronization, myocardial revascularization, valve repair techniques, latissimus dorsi cardiomyopathy, acorn cardiac support device, heart transplantation and mechanical assist devices do not cover all the needs. The recent progress in cellular and molecular biology allows the development of new therapies for heart failure. Transplantation of Autologous Cells: One of the most innovative consists in the transplantation of autologous ex-vivo expanded cells into the myocardium for heart muscle regeneration. This approach is called “cellular cardiomyoblasty”.Hintergrund: Die Behandlung der Herzinsuffizienz stellt trotz Pharmakotherapie, biventrikulärer Resynchronisation, interventioneller und kardiochirurgischer Revaskularisation, der Latissimus-doris-Kardiomyoplastie, der kardialen Assist-Systeme und der Herztransplantation unverändert eine therapeutische Herausforderung an Kardiologen und Herzchirurgen dar. Neue molekularbiologische Techniken sind die Voraussetzung für innovative Therapieansätze. Zu ihnen gehört die autologe Myoblastentransplantation von ex vivo expandiertem Skelettmuskelzellen ins Myokard zur Herzmuskelregeneration. Autologe Myoblastentransplantation: Vor den von der Arbeitsgruppe an der Universität Paris (Klinik Brussais) durchgeführten ersten drei Transplantationen von Skelettmuskelmyoblasten beim Menschen wurden u. a. Erfahrungen am Kardiotoxinmodell des Schafs vor und nach Myoblastentransplantation mittels Kolorkinesis-Echokardiographie (Abbildung 4) gesammelt. Die herzkatheterbasierte Applikation von Myoblasten wurde am gleichen Modell unter Verwendung des Noga-Systems (Abbildung 5) zum elektroanatomischen “Mapping” erfolgreich erprobt und die Verbesserung der regionalen Wandbewegung durch biventrikuläre Stimulation gezeigt. Eine De-novo-Angiogenese zeigte sich nur nach Vorbehandlung der Tiere mit VGEF. Der Erfolg einer Myoblastentransplantation hängt von der Zahl überlebender injizierter Myoblasten ab. Dies ist in der Randzone eines Infarkts oder bei experimenteller “Pacing-induzierter” dilatativer Kardiomyopathie besser als im Bereich einer Narbe. Bei den bisher drei am Menschen vorgenommenen autologen Transplantation von Skelettmuskelmyoblasten konnte eine Reduktion der Infarktgröße erreicht werden. Die Expansion der Myoblasten im autologen Serum ist dabei zur Vermeidung von immunologischen Abwehrmechanismen, die unter bovinem Serumalbumin als Nährmedium gezeigt wurden, von besonderer Bedeutung.

Timing of Renal Replacement Therapy after Cardiac Surgery: A Retrospective Multicenter Spanish Cohort Study

Background: The optimal time to initiate renal replacement therapy (RRT) in cardiac surgery-associated acute kidney injury (CSA-AKI) is unknown. Evidence suggests that the early use of RRT in critically ill patients is associated with improved outcomes. We studied the effects of time to initiation of RRT on outcome in patients with CSA-AKI. Methods: This was a retrospective observational multicenter study (24 Spanish hospitals). We analyzed data on 203 patients who required RRT after cardiac surgery in 2007. The cohort was divided into 2 groups based on the time at which RRT was initiated: in the early RRT group, therapy was initiated within the first 3 days after cardiac surgery; in the late group, RRT was begun after the 3rd day. Multivariate nonconditional logistic and linear regression models were used to adjust for potential confounders. Results: In-hospital mortality was significantly higher in the late RRT group compared with early RRT patients (80.4 vs. 53.2%; p < 0.001; adjusted odds ratio of 4.1, 95% CI: 1.6–10.0). Also, patients in the late RRT group had longer adjusted hospital stays by 11.6 days (95% CI: 1.4–21.9) and higher adjusted percentage increases in creatinine at discharge compared with baseline by 67.7% (95% CI: 28.5–106.4). Conclusions: Patients who undergo early initiation of RRT after CSA-AKI have improved survival rates and renal function at discharge and decreased lengths of hospital stay.

Dual-source CT coronary angiogram in heart transplant recipients in comparison with dobutamine stress echocardiography for detection of cardiac allograft vasculopathy.

Conventional coronary angiography (CCA) is the gold standard in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients. Dobutamine stress echocardiography (DSE) is a useful technique for screening. Dual-source computed tomography (DSCT) is the last generation of computed tomography scanners, which could be useful to noninvasively assess CAV. Thirty cardiac transplant recipients underwent DSE and DSCT coronary angiogram. Exclusion criteria were as follows: renal insufficiency, iodinated contrast media allergy, less than 12 months since transplant, and unstable clinical conditions. DSE showed ischemia in two patients. At DSCT scan 13 patients had a normal angiogram, 13 ones wall thickening and four significant diseases. DSCT showed a sensitivity of 100% with a specificity of 92%. DSCT allowed detection of more patients with CAV than DSE. Four patients showed significant CAV at DSCT compared with two at DSE. Thirteen patients showed initial signs of disease at DSCT despite a normal DSE.

External Validation and Comparison of Three Scores to Predict Renal Replacement Therapy after Cardiac Surgery: A Multicenter Cohort:

Purpose Cardiac surgery-associated acute kidney injury requiring renal replacement therapy (RRT) is independently associated with mortality. Several risk scores have been developed to predict the need for RRT after cardiac surgery. We have compared and verified the external validity of the three main available scores for RRT prediction after cardiac surgery: the Thakar score, the Mehta tool, and the Simplified Renal Index. Methods The risk scores were calculated in a cohort of 1084 adult patients, 248 of whom required RRT, who underwent open-heart surgery in 24 Spanish hospitals in 2007. The performance of the systems was determined by examining their discrimination (areas under the receiver operating characteristic curves (aROC) and calibration (Lemeshow-Hosmer chi-square goodness-of-fit statistics). Results: The aROCs in the Thakar score, the Mehta tool, and the Simplified Renal Index were 0.82, 0.76 and 0.79, respectively. The three scoring systems were poorly calibrated and tended to underestimate the actual need for RRT. Conclusions The Thakar score and the Simplified Renal Index discriminated well between low - and high-risk patients in our cohort, and Thakar outperformed the Mehta tool. These best-performing scores may aid in the selection of optimal therapy, facilitate the planning of hospital resource utilization, improve preoperative counseling, select participants for clinical trials of renal-protective therapies and enable an accurate comparison between different institutions or surgeons.

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

La cirugia coronaria esta avalada por unos excelentes resultados, bien documentados a largo plazo como consecuencia de la revascularizacion completa y la utilizacion de una o 2 arterias mamarias. En este articulo se revisan los resultados y las indicaciones de la cirugia y se valoran los nuevos retos y las oportunidades que incluyen la cirugia mas segura, menos agresiva y asociada a otros procedimientos quirurgicos. El objetivo es desarrollar estrategias ligadas a un ciclo innovador que adapte la cirugia a las necesidades de la poblacion, las nuevas tecnologias y a las actividades pioneras.

Platelet dysfunction in cardiopulmonary bypass: an experimental comparative study between a centrifugal and a new pulsatile pump.

The aim of this investigation was to study the effect of a new pulsatile pump for extracorporeal circulation (ECC) on platelet count and platelet function with respect to a Biomedicus centrifugal pump. Thirteen pigs, 8 in the pulsatile group (PG) and 5 in the centrifugal group (CG), underwent a partial extracorporeal circulation lasting 3h. The animals were sacrificed 3h post-ECC. The platelet study was both quantitative (platelet count) and qualitative (platelet function analysis) by assessing the closure time (CT) with a PFA- 100 system. The decrease in platelet number from basal to 3h post ECC was only significant in CG (p = 0.009). The platelet function was impaired in both groups, but the value of CT with col/ADP increased significantly only in CG (p < 0.001). The increase of CT with col/EPI was greater in CG (p = 0.07) than in PG (p = 0.2). The results indicated that the new pulsatile pump preserves platelets quantitatively and qualitatively well compared to a Biomedicus pump.

Bicaval anastomosis in a heart transplant recipient with left superior vena cava

We describe the surgical procedure of orthotopic heart transplantation (OHT) in a recipient with persistent left superior vena cava (LSVC) and isolated noncompaction of the left ventricle. The bicaval anastomosis technique was performed using and isolating his native coronary sinus to let the left superior vena cava drain into his own inferior vena cava through the native coronary sinus.

Cirugía de restauración ventricular después del estudio STICH

La insuficiencia cardiaca es uno de los problemas de salud publica de mayor envergadura. Los cambios de la geometria ventricular, con su repercusion en el pronostico y el numero limitado de donantes, ha generado un interes creciente para la aplicacion de cirugia de restauracion ventricular (SVR). Las tecnicas quirurgicas son revisadas, su correlacion con los fundamentos anatomicofisiopatologicos de la insuficiencia cardiaca y sus resultados son analizados. Los estudios clinicos de SVR aportan evidencia cientifica para mantener y potenciar su aplicacion, a pesar de los resultados de la hipotesis 2 del estudio STICH (Surgical Treatment for Ischemic Heart Failure). Presentamos un proyecto cuyo desarrollo hemos iniciado y que integra el Registro Latinoamericano de Cirugia de Restauracion Ventricular (SVRIR) y los estudios de mecanica computacional. Sus objetivos son realizar aportaciones al conocimiento de la fisiopatologia de la insuficiencia cardiaca, correlacionar las tecnicas quirurgicas con los fundamentos anatomicos y fisiopatologicos de la insuficiencia cardiaca, precisar los beneficios de la SVR y disenar tecnicas especificas para cada paciente.