Miguel A. Arnau

Ventricular natriuretic peptide (BNP) in heart transplantation: BNP correlation with endomyocardial biopsy, laboratory and hemodynamic measures

A prospective study of 81 heart transplant (HT) patients was carried out in order to evaluate the evolution of brain natriuretic peptide (BNP) levels in HT patients and compare them with the degree of rejection as determined by endomyocardial biopsy. All patients were subjected to endomyocardial biopsy (532), and determination of BNP and creatinine levels as well as hemodynamic parameters. A control group of 36 volunteers was included. BNP values were significantly greater in HT patients than in healthy volunteers. In the first 3 months, BNP levels in patients with treatable rejection were significantly greater than in patients without graft rejection, although evident overlapping was observed in both distributions and discriminatory potential was low. After the third month, BNP values were similar in patients with and without rejection. Creatinine levels were observed to increase over time after transplantation, but no correlation was observed between the creatinine and BNP levels. A significant positive correlation was observed between BNP and right ventricle and pulmonary arterial pressures.

Resonancia magnética nuclear en pacientes portadores de dispositivos de estimulación cardiaca

La resonancia magnetica esta actualmente contraindicada a los pacientes portadores de dispositivos de estimulacion cardiaca. Ante la necesidad de concretar los riesgos potenciales derivados de esta situacion, surgio este estudio. De forma prospectiva, se evaluaron parametros clinicos, electricos y tecnicos antes y despues de la realizacion de la prueba en 33 pacientes (5 desfibriladores automaticos implantables, 28 marcapasos), en los que se considero clinicamente indispensable realizarla. No se apreciaron complicaciones clinicas. Se detectaron dos casos de fallo temporal de telemetria, dos errores de deteccion durante la exploracion y una respuesta de seguridad en un marcapasos a frecuencia magnetica y salida maxima. No hubo limitaciones tecnicas en la adquisicion de imagenes ni alteraciones permanentes del funcionamiento de los dispositivos de estimulacion cardiaca.

Nuclear Magnetic Resonance Imaging in Patients With Cardiac Pacing Devices

Currently, nuclear magnetic resonance imaging is contraindicated in patients with a pacemaker or implantable cardioverter-defibrillator. This study was carried out because the potential risks in this situation need to be clearly defined. This prospective study evaluated clinical and electrical parameters before and after magnetic resonance imaging was performed in 33 patients (five with implantable cardioverter-defibrillators and 28 with pacemakers). In these patients, magnetic resonance imaging was considered clinically essential. There were no clinical complications. There was a temporary communication failure in two cases, sensing errors during imaging in two cases, and a safety signal was generated in one pacemaker at the maximum magnetic resonance frequency and output level. There were no technical restrictions on imaging nor were there any permanent changes in the performance of the cardiac pacing device.

Utilidad del electrocardiograma para predecir el lugar de la oclusión en el infarto agudo de miocardio anterior con enfermedad aislada de la arteria descendente anterior

Introduccion y objetivos En el infarto agudo de miocardio (IAM) anterior, el lugar de la oclusion de la arteria descendente anterior (DA) se relaciona con la extension de la necrosis y con el pronostico. El proposito del estudio fue valorar la utilidad del electrocardiograma (ECG) para predecir el lugar de la oclusion de la DA en pacientes con IAM anterior y enfermedad aislada de la DA. Metodos Estudio retrospectivo en el que se incluyen a 45 pacientes consecutivos con un primer IAM de localizacion anterior y enfermedad aislada de la DA. Analizamos el ECG que mostro la mayor desviacion del segmento ST (ST) previo al tratamiento fibrinolitico y lo correlacionamos con el nivel lesional en la DA en coronariografia realizada antes del alta hospitalaria en relacion con la primera septal dominante y primera diagonal, distinguiendo: territorio septal afectado («S»), territorio diagonal afectado («D»), ambos afectados («S + D») o ninguno. Resultados El descenso del segmento ST en las derivaciones II, III o aVF fue un potente predictor de lesion proximal en la DA en las localizaciones angiograficas «S + D», «S» y «D» (p = 0,003, p = 0,04 y p = 0,02, respectivamente). El ascenso del ST en II, III o aVF unicamente se observo en pacientes con una DA desarrollada que daba la vuelta al apex y se relaciono con lesion distal a la diagonal dominante (p Conclusiones En el IAM anterior y enfermedad exclusiva de la DA, el ECG puede ser una herramienta util en la prediccion del nivel lesional de la DA en relacion con sus ramas principales.

Análisis de los factores que pueden influir en la aparición del fallo agudo del corazón trasplantado

Introduction and objective. Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF. Material and method. In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model. Results. The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01). Conclusions. AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

Is the prognosis poorer in heart transplanted patients who develop a right bundle branch block

BACKGROUND Currently studies conflict on the impact on mortality of right bundle branch block development after transplantation. Most studies conclude that right bundle branch block does not affect patient survival. However, no distinction is made between patients in whom right bundle branch block progresses and those in whom it remains unchanged during follow-up. The objective of this study is to assess clinical or survival differences between patients who develop right bundle branch block and those who do not, and also to analyze these differences depending on progression of this conduction abnormality. MATERIALS AND METHODS Ninety-seven consecutive heart transplant recipients with more than 1 years survival were analyzed. Twelve-lead standard ECGs were performed during the first week after transplantation, which allowed for classification of patients depending on the presence or absence of right bundle branch block. Subsequently, throughout the first year, 2 groups were identified, depending on increase of the conduction defect. The groups were compared and factors determining the presence of right bundle branch block and progression of the conduction defect were found. Survival curves for the conduction defect were also compared. RESULTS Fifty percent of the patients developed right bundle branch block after transplantation; it was progressive in 10. Progressive right bundle branch block was related to greater renal dysfunction (odds ration [OR] = 10.8; confidence interval [CI] = 2-58; p = 0.006), a larger number of rejections (p = 0.01), and a greater death rate (OR = 12.8; CI = 2.5-64; p = 0.002). The presence of progressive right bundle branch block was an independent predictor of long-term mortality (OR = 27.9; CI = 4.2-186.3; p = 0.0006). CONCLUSIONS The development of right bundle branch block after transplantation is related to intraoperative factors and to a greater number of rejections. The presence of this conduction disorder, particularly if it progresses during the first year, identifies a sub-group of patients with a poorer long-term prognosis.

Deregulated hepatic microRNAs underlie the association between non-alcoholic fatty liver disease and coronary artery disease

Non‐alcoholic fatty liver disease (NAFLD) appears to be a new risk factor for the development of coronary artery disease (CAD). Members of a class of non‐coding RNAs, termed microRNAs (miRNAs), have been identified as post‐transcriptional regulators of cholesterol homoeostasis and can contribute to the development of NAFLD. The aims of this study were to (i) to assess the relationship between NAFLD and sudden cardiac death (SCD) from severe CAD in forensic autopsies and (ii) to quantify several hepatic miRNAs previously associated with lipid metabolism and NAFLD to correlate their expression with the presence of NAFLD, CAD, obesity parameters and postmortem lipid profile.

The presence of epsilon waves in a patient with acute right ventricular infarction

Epsilon wave is an unusual electrocardiographical finding, which may appear in other pathological conditions besides the arrhythmogenic right ventricular dysplasia, particularly in the acute myocardial infarction of the right ventricle, the inferior, or the posterior wall of the left ventricle. Its real incidence in these acute coronary syndromes remains unknown and will be probably difficult to assert, since it may be unnoticed by inexperienced physicians because of its little voltage. The outstanding interest of this case lies in the clear electrocardiographical images and in the step‐by‐step differential diagnosis discussed by the authors.

Impacto de la diabetes mellitus en el paciente con trasplante cardiaco

Introduccion y objetivos Actualmente, el impacto de la diabetes mellitus en los pacientes con trasplante cardiaco es controvertido y su efecto sobre la mortalidad y otras complicaciones, como las infecciones y los rechazos, no esta completamente aclarado. El objetivo de este estudio es analizar estos efectos en nuestra poblacion de pacientes trasplantados. Metodos Se ha estudiado a una poblacion de 365 pacientes consecutivos con trasplante cardiaco desde noviembre de 1987 hasta mayo de 2003, dividiendolos en 3 grupos en funcion de la presencia de diabetes pretrasplante (grupo 1), diabetes de novo (grupo 2) y no diabeticos (grupo 3). Se analizaron variables tanto basales como de complicaciones evolutivas, y los resultados se compararon mediante test t de Student, test χ 2 y metodo de Kaplan-Meier para la supervivencia. Resultados No apreciamos diferencias entre grupos en la supervivencia al ano (p = 0,24) ni a 5 anos (p = 0,32). Los pacientes de los grupos con diabetes mellitus pretrasplante y de novo tenian mayor edad (54,6 frente a 54,9 frente a 50,6 anos; p = 0,04), mayor prevalencia de hipertension arterial (el 48, el 36 y el 23%; p = 0,001) y mayor porcentaje de tratamiento con tacrolimus (el 10, el 12 y el 4%; p = 0,04) y esteroides (el 92, el 86 y el 70%; p = 0,001). Evolutivamente, estos 2 grupos presentan mayor incidencia de rechazo (el 64, el 70 y el 45%; p = 0,001). Conclusiones La diabetes previa al trasplante o de novo no tuvo impacto negativo sobre la supervivencia de nuestros pacientes trasplantados. Su presencia se asocial al tratamiento con esteroides y tacrolimus. En estos pacientes seria deseable realizar un ajuste individualizado de la inmunodepresion.

Takotsubo syndrome with coronary lesions

Tako-Tsubo syndrome occurs predominantly in women over 60 years of age with a history of stress. The presentation resembles acute coronary syndrome, with electrocardiogram changes that normalize within 97-191 days.1 The echocardiogram shows decreased apical contractility with basal hyperkinesia and occasionally, intraventricular gradients,2 and the alterations return in 1-3 weeks. Enzyme elevation is minimal for the alterations described.3 Early catheterization reveals normal coronaries or insignificant lesions.4,5 We present a case of Tako-Tsubo syndrome with significant coronary lesions that do not explain the clinical symptoms. To our knowledge, no similar cases have been described. A 61-year-old woman, smoker, with hypertension, and depressive syndrome currently under treatment was seen in the emergency room for oppressive precordial pain radiating to the left arm that worsened upon inspiration, which she experienced after seeing a recently deceased family member on a video tape. The symptoms did not clearly vary with posture, and were accompanied by sweating and nausea. The clinical evolution was over a period of 3 hours. The electrocardiogram (ECG) showed concave ST segment elevation in leads V4-V6, with peaked T waves in all precordial series and short PR-interval in lead II. To investigate pericarditis and the changes in pain with respiration, the patient underwent echocardiography, which showed apical dyskinesia with good basal contractility and a subaortic gradient of 30 mm Hg (Figure 1). Laboratory analysis disclosed a troponin-T concentration of 0.71 and normal creatine kinase. On the basis of suspected Tako-Tsubo with extensive dyskinesia, together with a dubious ECG and the patient’s clinical profile, coronary angiography was performed to avoid fibrinolysis. The findings included apical dyskinesia (Figure 2) and two-vessel disease (right coronary and circumflex) with left dominance and a highly developed left anterior descending (LAD) artery; the coronary lesions were not consistent with the contractility alterations. The patient was admitted to intensive care and treatment was started with beta-blockers and antiplatelet agents, with satisfactory clinical progress. An ultrasound examination at 7 days showed recovery of apical function and resolution of the subaortic dynamic gradient, ECG changes indicating a trend toward generalized subepicardial ischemia. Tako-Tsubo syndrome was originally described in 1990, although the first series of cases was published in 2001, in Japan.6 Other series from different countries, including Spain, were published later, indicating the global nature of the syndrome. The etiopathogenesis of this syndrome is still not understood. The mechanisms most commonly cited include: