María J. Paniagua-Martín

Utilidad de la escala INTERMACS para estratificar el pronóstico tras el trasplante cardiaco urgente

INTRODUCTION AND OBJECTIVES Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). METHODS Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. RESULTS Patients at the INTERMACS 1 level (n=31) more frequently had ischemic heart disease (P=.03) and post-cardiothomy shock (P=.02) than patients at the INTERMACS 2 (n=55) and INTERMACS 3-4 (n=25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (P=.001), a higher frequency of use of mechanical ventilation (P<.001), intraaortic balloon (P=.002) and ventricular assist devices (P=.002), and a higher frequency of preoperative infection (P=.015). The INTERMACS 1 group also presented higher central venous pressure (P=.02), AST (P=.002), ALT (P=.006) and serum creatinine (P<.001), and lower hemoglobin (P=.008) and creatinine clearance (P=.001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (P=.03) and postoperative need for renal replacement therapy (P=.004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, P=.023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p=0.013; HR 6.8, IC 95% 1.2-39.1). CONCLUSIONS Our results suggest that the INTERMACS scale may be a useful tool to stratify postoperative prognosis after urgent HT.

Quinolone-related Achilles Tendinopathy in Heart Transplant Patients: Incidence and Risk Factors

BACKGROUND A high incidence of Achilles tendinopathy--tendinitis or rupture--has been observed after quinolone treatment in lung and kidney transplant patients. In the absence of relevant published data, we aimed to determine its incidence, clinical features, risk factors and outcome among heart graft recipients. METHODS We studied the clinical records of all adult heart transplant patients who were prescribed quinolones at our center between August 1995 and September 2006. Achilles tendinopathy had been diagnosed clinically, with ultrasound assessment when necessary. In all cases, quinolone treatment had been terminated upon diagnosis of tendinopathy. RESULTS During this period, quinolones had been given on 242 occasions to 149 heart transplant patients (33 women, 116 men). Achilles tendinopathy developed on 14 occasions (5.8%; 95% confidence interval: 2.8% to 8.7%), affecting 13 men and 1 woman (mean age: 62 years). Three cases involved tendon rupture, and bilateral tendinopathy was present in 8 cases. The median time between the start of treatment and onset of symptoms was 2.5 days, with 12 patients being asymptomatic 2 months after drug withdrawal. Independent risk factors for tendinopathy were renal dysfunction (p = 0.03) and increased time between transplantation and treatment (p = 0.005). Incidence was not influenced by the type, dose or previous administration of quinolones, or by the immunosuppressive regimen. CONCLUSIONS Quinolone-related Achilles tendinopathy is frequent among heart transplant patients, especially in the presence of renal dysfunction or lengthy post-transplantation survival. If no alternative anti-bacterial therapy is available for high-risk patients, close clinical surveillance should be warranted.

Prevalence and prognostic value of cardiac allograft vasculopathy 1 year after heart transplantation according to the ISHLT recommended nomenclature

Although cardiac allograft vasculopathy (CAV) is the major impediment to long-term survival after heart transplantation (HT), it is only recently that standards governing the grading of this entity have been introduced in the form of the International Society for Heart and Lung Transplantation’s recommended nomenclature (ISHLT-RN), which is based on angiographic findings and graft function. The prognostic value of this grading system remains unknown. In this study we evaluated the prevalence and prognostic significance of ISHLT-RN CAV grades assigned 1 year after HT. We retrospectively studied 169 consecutive patients who underwent HT at our center between January 2000 and December 2009, and coronary angiography 1 year after HT (median time 12.3 months, interquartile range 9.7 to 13.7 months). Patients’ baseline characteristics (Table 1) were

Lung Cancer after Heart Transplantation: Results from a Large Multicenter Registry

In this study we analyzed Spanish Post‐Heart‐Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post‐HT follow‐up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post‐HT. Incidence increased with age at HT from 149 per 100 000 person‐years among under‐45s to 542 among over‐64s; was 4.6 times greater among men than women; and was four times greater among pre‐HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age‐at‐diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan–Meier 2−year survival to 70% versus 16% among inoperable patients.

Prevention and treatment of coronary artery vasculopathy.

Purpose of reviewCardiac allograft vasculopathy (CAV) is still one of the major causes of death following heart transplantation. Here, we review the recent advances in its prevention and treatment. Recent findingsPreventive measures comprise control of classical risk factors, prophylaxis against cytomegalovirus, avoidance of graft endothelial damage during heart transplantation, and prevention of acute rejection. These measures can be effective if begun early. The treatment options for established CAV are limited, percutaneous revascularization and coronary artery bypass graft only being viable for a minority of patients because of the diffuse nature of CAV. Retransplantation is the only definitive therapy for CAV and may be considered for suitable patients with advanced CAV and allograft dysfunction. One of the most promising developments in the recent years is the use of mTOR inhibitors, which can now be regarded as effective in preventing CAV in de novo patients; their role in the treatment of established CAV is still uncertain despite some encouraging recent findings. SummaryThe implementation of measures and lifestyles that help prevent CAV should be a priority of postheart transplantation management. Research should urgently evaluate mTOR inhibitors for the treatment of established CAV.

Long-Term Outcome in Heart Transplant Patients With Pretransplant Malignancies

INTRODUCTION Neoplasms have classically been considered a contraindication for heart transplantation (HT) because of the possibility of recurrence during immunosuppressive therapy. There are few cases of patients who suffered a pretransplant malignancy (PTM); however the appropriate interval free of a malignancy (IFoM) before heart transplantation is unclear. Our study sought to determine the long-term outcomes after transplantation among patients who had suffered a prior neoplasm compared with our overall cohort. METHODS This retrospective, single-center study included 595 heart transplant recipients ungrafted between 1991 and 2009. We determined PTM location, histology, and IFoM. We examined donor and recipient factors and post-HT data of rejections, infections, neoplasms, and survival associated with a poor prognosis. RESULTS Twelve patients with different types, locations, and histological grades of PTM represented 66.7% women versus 16.1% women in the overall series (P<.01). There were no differences in recipient age or clinical characteristics (diabetes mellitus, arterial hypertension, previous renal failure, or New York Heart Association class), number of emergency cases, or graft ischemia time. Mean IFoM was 114.3 months (range=5.3-350.4). After heart transplantation, there were no significant differences between the number of infections (47.9%; n=[279] vs 33.3% n=4; P=.39), rejection episodes (44.4% [259] vs 50% [6], P=0.77) or post-HT malignancies (12.2% [70] vs 0%, P=0.37) between the overall series and the patients with PTM. None of the patients with PTM suffered a recurrence of the neoplasm. Actuarial survivals at 1, 3, and 5 years were 82%, 76%, and 70% among patients without PTM and 75%, 75%, and 56% among those with PTM (P=.70). CONCLUSION Patients with PTM and an appropriate IFoM with regard to tumor lineage showed similar rates of survival and complications as those of the overall series. This series suggested that appropriately selected patients with a cured PTM can be candidates for HT.

Sudden Cardiac Death of Two Heart Transplant Patients With Correctly Functioning Implantable Cardioverter Defibrillators

It is unclear whether the usual criteria for implantation of implantable cardioverter defibrillators in patients at risk of sudden death can be generalized to heart transplant recipients. We describe sudden death in 2 heart transplant recipients despite correctly functioning implantable cardioverter defibrillators. The scant relevant literature is reviewed. We conclude that implantable cardioverter defibrillators are unlikely to assist heart transplant recipients with severe coronary allograft vasculopathy and poor ventricular systolic function, the group with the highest incidence of sudden death.

Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry

The results of studies on the association between sex mismatch and survival after heart transplantation are conflicting. Data from the Spanish Heart Transplantation Registry. From 4625 recipients, 3707 (80%) were men. The donor was female in 943 male recipients (25%) and male in 481 female recipients (52%). Recipients of male hearts had a higher body mass index (25.9 ± 4.1 vs. 24.3 ± 3.7; P < 0.01), and male donors were younger than female donors (33.4 ± 12.7 vs. 38.2 ± 12.3; P < 0.01). No further relevant differences related to donor sex were detected. In the univariate analysis, mismatch was associated with mortality in men (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.06–1.32; P = 0.003) but not in women (HR, 0.91; 95% CI 0.74–1.12; P = 0.4). A significant interaction was detected between sex mismatch and recipient gender (P = 0.02). In the multivariate analysis, sex mismatch was associated with long‐term mortality (HR, 1.14; 95% CI 1.01–1.29; P = 0.04), and there was a tendency toward significance for the interaction between sex mismatch and recipient gender (P = 0.08). In male recipients, mismatch increased mortality mainly during the first month and in patients with pulmonary gradient >13 mmHg. Sex mismatch seems to be associated with mortality after heart transplantation in men but not in women.

Fulminant Hepatic Failure due to Varicella Zoster in a Heart Transplant Patient: Successful Liver Transplant

Fulminant hepatic failure is a rare complication of infection by varicella zoster virus that is favored by immunosuppression. Within 1 week, a 43-year-old male heart transplant recipient who was admitted with epigastric pain successively developed a generalized vesicular rash, hepatitis, and secondary multiorganic failure involving encephalopathy, despite treatment with acyclovir (since Day 2) and varicella zoster virus immunoglobulin (since Day 6). Emergency liver transplantation was performed on Day 9, and 36 months later, his heart and liver function are normal.

Body surface area as a prognostic marker in chronic heart failure patients: results from the Heart Failure Registry of the Heart Failure Association of the European Society of Cardiology

The ‘obesity paradox’ is consistently observed in patients with heart failure (HF). We investigated the relationship of body surface area (BSA) to mortality and hospitalizations in patients with chronic HF.