N Manito

Acute myocardial infarction with cardiogenic shock: treatment with mechanical circulatory assistance and heart transplantation

UNLABELLEDnThe mortality of cardiogenic shock (CS) after an acute myocardial infarction (AMI) still remains high. Thrombolysis, PTCA or CABG, when possible, can improve the results, but when all the treatments fail death is almost certain.nnnOBJECTIVEnWe investigate the use of the mechanical circulatory assistance (MCA) and heart transplantation (HT) to improve the adverse results in this irreversible situation.nnnMETHODSnAmong 11 patients with irreversible CS after an AMI we used a MCA (Abiomed BVS-5000). After improvement and hemodynamic stabilization, we performed heart transplantation in 7 patients of mean age 52 years (35-60) including two women. The MCA was univentricular in 7 patients and biventricular in 4. Mean duration of the MCA was 5 days (1-12).nnnRESULTSnThree patients died during the MCA: two due to cerebrovascular accidents and one multiorgan failure. Weaning was possible in one patient. Among Seven transplanted patients one died due to sepsis. Seven (64%) patients are long-term survivors.nnnCONCLUSIONnWhen all the treatments have failed for CS after an AMI, MCA may be used as a bridge to heart transplantation in a select group of patients where the procedure is not contraindicated. The long-term results of 64% survivors in our experience is satisfactory.

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation☆

BACKGROUNDnAbnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation.nnnMETHODSnThe endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA).nnnRESULTSnAt early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction.nnnCONCLUSIONSnEndothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.

Sirolimus in heart transplantation: a single center initial experience.

Sirolimus (SRL) is a potent non-nephrotoxic immunosuppressant. In our unit, SRL was administered to 17 heart transplant (HT) recipients at 1770+/-1234 days posttransplant surgery, for the following reasons: (1) calcineurin inhibitor (CI) withdrawal due to renal insufficiency (RI; n=6); (2) neurotoxicity (n=1) and pancytopenia (n=1); (3) vascular graft disease (VGD) treatment (n=5); (4) immunosuppression optimization due to lung cancer (n=2); (5) CI use was delayed due to postsurgery RI (n=2). The mean follow-up was 190+/-165 days. Mean SRL doses (mg)/concentrations (ng/mL) at 7 (n=17), 30 (n=14), and 180 (n=8) days were: 1.2+/-0.6/5.9+/-6; 1.6+/-0.8/4.8+/-3.1; and 1.7+/-1.0/5.2+/-3.7. Among group 1, CI patients were discontinued without favorable functional impact. Neurotoxicity and pancytopenia improved, but there were no major clinical events in the VGD group. One bridge to CI was successfully performed (postsurgery RI). Total leukocyte count fell while hemoglobin, platelet, and cholesterol profiles were not affected. Ten of 15 patients (67%) were discontinued from CI without rejection and with a dose reduction of mycophenolate mofetil. There were 8 episodes (47%) of SRL-related toxicity, leading to 4 discontinuations (23%); 8 patients (47%) have died during follow-up. This retrospective analysis of outcomes in the context of severe complicated patients suggests that more premature introduction SRL is preferable, particularly in a large patient cohort.

Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure: the LION-HEART multicentre randomised trial: Levosimendan in advanced HF: the LION-HEART trial

The LION‐HEART study was a multicentre, double‐blind, randomised, parallel‐group, placebo‐controlled trial evaluating the efficacy and safety of intravenous administration of intermittent doses of levosimendan in outpatients with advanced chronic heart failure.

Ventricular Circulatory Support with the Abiomed System as a Bridge to Heart Transplantation

The Abiomed system was initially designed as a mechanical support for postcardiotomy failure, but it has been also used as a bridge to heart transplantation. We review our experience with this system since November 1992 in 10 patients. The mean age was 46 years. Nine were men. The underlying cardiac disease was ischemic cardiomyopathy in 8, dilated cardiomyopathy in 1, and acute myocarditis in 1. The cardiogenic shock was due to an acute myocardial infarction in 7 (one after coronary bypass and another with a left ventricular rupture), end-stage cardiac insufficiency in 2 (already on the heart transplantation waiting list), and early graft failure in 1. The implantation of the system was performed without extracorporeal circulation. The type of support was biventricular in 4 and left ventricular in 6. The hemodynamic improvement was important in terms of the vital constants and cardiac output. The mean flow of the right pump was 4.61/min and that of the left pump, 4.41/min. Three (30%) died under mechanical support for a mean of 7 days, six (60%) were successfully transplanted after a mean of 3.5 days, and one (10%) was able to be weaned 7 days later. Only one (10%) died, after 2 months because of sepsis. All survivors (60%) are asymptomatic. Bleeding (50%) and thromboembolism (40%) were the most frequent complications. The Abiomed system proved to be useful in the recovery from cardiogenic shock, especially after acute myocardial infarction. It can be managed simply and the cost is limited. Of our supported patients, 60% are long-term survivors. This system can also be used as a bridge of short duration to heart transplantation.

Rehabilitation in Heart Failure: Update and New Horizons

Purpose of the reviewHeart failure is very prevalent and exercise intolerance is one of its main symptoms. Various studies and meta-analysis have provided scientific evidence regarding the improvement of functional capacity and quality of life in patients with heart failure who undertake a cardiac rehabilitation program. This paper reviews the evidence published in recent years regarding the efficacy and safety of physical exercise, as well as the different exercise modalities that should be a part of the treatment of heart failure patients.Recent findingsExercise training in heart failure is safe and effective. High-intensity interval training, especially when associated with strength exercises and inspiratory muscle training, offers the most benefits compared with the traditional continuous training of moderate intensity. It is also better tolerated in heart failure patients and this increases adherence. However, we are in need of a big randomized study in patients with heart failure in order to fully establish the best exercise modality in these patients.SummaryPatients with heart failure should be referred to a multidisciplinary Cardiac Rehabilitation program and receive an individual exercise prescription based on risk stratification, exercise capacity, and patient’s preference. There is no single exercise training program that covers all the individual patients’ needs. Therefore, in most cases, a combination of exercise programs, such as aerobic interval or continuous training, strength exercise, and inspiratory muscle training, is needed.