Montserrat Cardona

Pulmonary Hypertension Is Related to Peripheral Endothelial Dysfunction in Heart Failure With Preserved Ejection Fraction

Background—Pulmonary hypertension (PH) and collagen metabolism abnormalities are prevalent in patients with heart failure with preserved ejection fraction (HFpEF). Peripheral endothelial dysfunction (PED) has been described in HF and in pulmonary arterial hypertension. Our aim is to determine whether PH is associated with PED and impaired collagen metabolism in patients with HFpEF.; Methods and Results—Flow-mediated dilation of the brachial artery, matrix metalloproteinase-2 and matrix metalloproteinase-9, tissue metalloproteinase inhibitor 1, and C-terminal propeptide of type I procollagen were determined in 28 patients with HFpEF and 42 hypertensive controls. Patients with systolic pulmonary artery pressure >35 mm Hg on echocardiogram underwent a right heart catheterization. Patients with HFpEF had more severe PED than controls: flow-mediated dilation 1.95% (−0.81 to 4.92) versus 5.02% (3.90 to 10.12), P=0.002. Twenty patients with PH underwent right heart catheterization: mean pulmonary artery pressure 38 (27–52) mm Hg, wedge capillary pressure 18 (16–22) mm Hg, pulmonary vascular resistance 362 (235–603) dyn s cm-5. There was a significant inverse correlation between flow-mediated dilation and pulmonary vascular resistance in patients with HFpEF and PH (r=−0.679; P=0.002). Patients with HFpEF showed higher matrix metalloproteinase-2 and C-terminal propeptide of type I procollagen values than hypertensive controls. Patients with HFpEF and higher C-terminal propeptide of type I procollagen values also had higher mean pulmonary artery pressure (r=0.553; P=0.014), transpulmonary gradient (r=0.560; P=0.013), and pulmonary vascular resistance (r=0.626; P=0.004). Conclusions—In patients with HFpEF, there is a significant correlation between PED and pulmonary vascular resistance. Collagen metabolism was more impaired in patients with HFpEF and PH. PED and collagen metabolism assessment could be useful tools to identify patients with HFpEF at risk of developing PH.

Long-term prognostic value of elevated heart rate one year after heart transplantation.

BACKGROUND Elevated heart rate (HR) is associated with adverse cardiovascular outcome in the general population and in patients with cardiovascular disease. Elevated HR due to graft denervation is often found in heart transplantation (HTx) patients; the effect on graft survival and vasculopathy is unclear. Thus, the aim of this study was to evaluate the role of elevated HR at 12 months post-HTx and its power to predict HTx long-term outcome. METHODS We evaluated retrospectively a prospective database of 312 patients undergoing HTx at two centers. HR was registered at 12 months post-HTx. The median HR was used as a cutoff point. Cox regression analysis was performed with variables known to be clinically relevant to mortality and those selected from the univariate analysis. RESULTS During a mean follow-up of 5.5 ± 2.8 years there were 58 deaths (19%). Patients with a HR ≥ 90 bpm (median HR) at 12 months had an increased risk for all-cause mortality (Hazard Ratio=2.4, 95% CI 1.2 to 4.5, p=0.009) and mortality related to coronary allograft vasculopathy (CAV) (Hazard Ratio=3.0, 95% CI 1.25-7.14, p=0.01). Multivariate analysis showed that a HR ≥ 90 bpm independently predicted mortality (HR 3.2, 95% CI 1.4-7.1, p=0.004). CONCLUSIONS Elevated HR measured at 12 months after HTx is an independent predictor of all-cause mortality in HTx recipients. A HR ≥ 90 bpm identifies a group of patients at high risk of death and CAV-related mortality at mid- to long-term.

Pólipos endometriales: riesgo de malignización y correlación clínico-anatómica

Resumen Objetivo Conocer la incidencia de polipos endometriales malignos en funcion del estado hormonal, la presencia o no de hemorragia uterina anormal (HUA), el uso de tamoxifeno (TMX) y de terapia hormonal sustitutiva (THS). Material y metodos Se analizan 1.822 polipectomias histeroscopicas. Tomaban THS 85 pacientes y TMX, 150. Resultados Los polipos de pacientes premenopausicas presentan mas HUA que los de las posmenopausicas. Se hallaron 16 polipos histologicamente malignos (0,87%). De estos, 14 se extirparon a pacientes posmenopausicas, 11 de ellas presentaban HUA. Entre pacientes premenopausicas se resecaron 2 polipos malignos, uno de ellos era asintomatico. No se detectaron polipos malignos entre pacientes con THS. Se encontraron 4 polipos malignos entre mujeres con tratamiento con TMX, 2 de ellos eran asintomaticos. Conclusion La reseccion sistematica de los polipos endometriales permite detectar todos los polipos malignos, incluso en los casos de pacientes asintomaticas y/o premenopausicas.

Primary immunosuppression and outcome differences after heart transplantation: tacrolimus versus cyclosporine.

BACKGROUND The superiority of tacrolimus (Tac) as primary immunosuppression for heart transplantation (HT) compared with cyclosporine (CsA) is still under debate. Outcomes of comparison studies are not consistent; the duration of these studies has been limited. The aim of this study was to evaluate long-term outcomes of patients undergoing HT based on primary immunosuppression regime. METHODS AND RESULTS We analyzed a single-center registry of all HT patients between 1998 and 2009, comparing outcomes based on primary immunosuppressions (Tac or CsA). Patients who died before starting immunosuppression were excluded. A total of 197 patients entered the study; 103 received Tac and 94 CsA. There were no differences between groups in baseline characteristics, United Network for Organ Sharing status 1A or ventricular assist device use, except for ischemia time (195 ± 50 min in Tac group vs 182 ± 55 min in CsA; P = .08) and days on waiting list (164 ± 155 vs 100 ± 73; P < .001). After mean follow-ups of 4.5 ± 2.3 years in the Tac group and 6.3 ± 4.3 years in the CsA group, there were 19 and 36 deaths, respectively. Kaplan-Meier analysis showed increased survival for the Tac group (log rank P = .04). Tac also was significantly superior to CsA regarding mortality (relative risk 0.55; 95% confidence interval, 0.31-0.98; P = .04). CONCLUSIONS In our series the use of tacrolimus resulted in improved long-term survival compared with cyclosporine. At 1-year follow-up, there were no differences in acute rejection episodes or the appearance of vasculopathy.

Comparación de la tasa de reestenosis entre stents convencionales y stents farmacoactivos en la enfermedad vascular del injerto

BACKGROUND AND OBJECTIVE To assess whether there are differences in the rate of restenosis between bare metal stents (BMS) and drug eluting stents (DES) implanted for the treatment of cardiac allograft vasculopathy (CAV). PATIENTS AND METHODS This retrospective study describes the baseline characteristics, clinical and angiographic evolution of a sample of heart transplant patients treated with coronary stent implantation due to CAV. RESULTS We analyzed the follow-up of 40 stents (17 BMS and 23 DES). Mean follow-up was 28 ± 18 months (range 12 to 84). The DES group had a lower rate of active smoking, a higher percentage of residual stenosis and an increased use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Control angiography was performed in 33 stents (82%). In the BMS group (n=15), 8 restenosis were identified (53%) whereas 2 (11%) were seen in the DES group (n=18) (P=.02). CONCLUSION In this series a lower rate of restenosis was observed in the DES group, attributable to the effect of the drug released locally by the stent.

The use of inhaled sevoflurane during operative hysteroscopy is associated with increased glycine absorption compared to intravenous propofol for maintenance of anesthesia

STUDY OBJECTIVE To compare the effects of anesthesia maintenance drugs (inhaled sevoflurane versus intravenous propofol) used in general anesthesia on the absorption of glycine 1.5% solution during hysteroscopy. DESIGN Prospective comparative study. SETTING Tertiary care university hospital. PATIENTS One hundred fifteen women undergoing hysteroscopy. INTERVENTIONS Women were assigned to receive general anesthesia with inhaled sevoflurane (n = 77) or intravenous propofol (n = 38) to maintain anesthesia. MEASUREMENTS The primary endpoint was clinically relevant glycine 1.5% absorption (>1000 mL), while secondary endpoints were the median of glycine absorption, operative time, complications and the incidence of discontinuation of the hysteroscopic procedure due to excessive glycine 1.5% absorption. MAIN RESULTS Maintenance with sevoflurane produced significantly increased absorption of glycine 1.5% solution compared to intravenous anesthesia (264 vs 202 mL, P = .007). Clinically relevant absorption rates (>1000 mL) were observed in the sevoflurane group (P = .04) while none of the women receiving intravenous anesthesia reached this absorption level. No cases of severe post-operative hyponatremia (Na(1+)<125 mmol/L) or adverse events derived from glycine 1.5% absorption were reported. No major complications (such as perforations, severe hemorrhage or infection) were presented during the interventions. CONCLUSIONS The results of the present study show that the use of inhaled sevoflurane is associated with significantly increased glycine 1.5% absorption compared to intravenous propofol for the maintenance of anesthesia. However, further randomized controlled trials are needed to assess the possible mechanisms and risk factors involved in the higher absorption induced by sevoflurane.

Adenocarcinoma de cérvix diagnosticado por histeroscopia

Resumen Paciente menopausica de 48 anos que ingresa por sospecha de enfermedad inflamatoria pelvica. En la ecografia se observo endometrio engrosado. La citologia fue negativa y la biopsia endometrial establecio el diagnostico de endometritis sin signos de malignidad, con cultivo positivo para Streptococcus pneumoniae. Al mes se realizo una nueva citologia que presento celulas glandulares de probable origen endometrial, pero sin atipias, y una biopsia endometrial compatible con hyperplasia endometrial compleja. En la histeroscopia se observo una mucosa irregular con vascularizacion aumentada en el orificio cervical interno. La biopsia fue informada como adenocarcinoma de tipo endocervical, por lo que se realize intervencion de Schauta-Amreich y linfadenectomia pelvica. En la histeroscopia deben biopsiarse o extirparse todas las alteraciones que encontremos.

Estudio aleatorizado del dispositivo liberador de levonorgestrel frente a resección endometrial para el tratamiento de la menorragia

Resumen Objetivo Tratamiento de la menorragia mediante reseccion endometrial y dispositivo liberador de levonorgestrel (LNG-IUS). Material y metodos Estudio aleatorizado; en 25 pacientes se realiza una reseccion endometrial y en 25 se coloca un LNG-IUS, con un seguimiento a 12 meses. Las variables estudiadas fueron la concentracion de hemoglobina, el patron de sangrado menstrual y el grado de satisfaccion. Resultados En ambos grupos se incremento la hemoglobina y el patron de sangrado mas frecuente fue el de amenorrea o hipomenorrea. El spotting fue el sintoma adverso mas comun para el LNG-IUS. El grado de satisfaccion fue del 94% en el grupo de reseccion y el 86% en el de LNG-IUS. Conclusiones Ambos tratamientos son efectivos para reducir el sangrado menstrual. Levonorgestrel intrauterine system versus endometrial resection for the treatment of menorrhagia: a randomized study