Rafael Martín-Durán

Aortic valve replacement with freehand autologous pericardium

Fifty-one patients with a mean age of 31.2 years underwent aortic valve replacement with glutaraldehyde-treated autologous pericardium. Pure aortic regurgitation was present in 28 (54.9%), stenosis in 9, and mixed disease in 14. Simultaneous mitral valve repair was done in 17 patients and replacement in 1. There were no hospital and two late deaths. Three patients required reoperation because of failure of the pericardial valve as a result of infective endocarditis in two (5 and 31 months after operation) and commissural tear at 8 months in another. One patient underwent reoperation at 24 months because of failure of the mitral valve repair. The pericardial aortic valve, which had 2+ regurgitation since the first operation, was also replaced. Macroscopic and microscopic examination findings in the excised pericardium were excellent. No thromboembolic events have been detected and no patient received anticoagulation therapy except one after mitral valve reoperation and replacement with a mechanical valve. The actuarial survival was 84.53% +/- 12.29% at 60 months, freedom from failure of the aortic reconstruction 83.83% +/- 8.59%, and freedom from any event 72.59% +/- 12.79%. Doppler echocardiographic study at most recent follow-up showed a mean gradient of 12.56 +/- 8.10 mm Hg and mean regurgitation on a scale from 0 to 4+ of 0.80 +/- 0.66. Although the maximum follow-up is only 5 years, the results obtained so far encourage us to continue replacing the aortic valve with stentless autologous pericardium.

Clinical course and predictors of death in prosthetic valve endocarditis over a 20-year period

OBJECTIVE To compare early and late outcome of patients with prosthetic valve endocarditis treated medically versus surgically and to determine predictors of in-hospital death. We retrospectively reviewed patients clinical records, including laboratory findings, surgery, and pathologic files, in an acute-care, 1200-bed teaching hospital. METHODS One hundred thirty-three episodes of definite prosthetic valve endocarditis as defined by the Duke University diagnostic criteria occurred in 122 patients from January 1986 to December 2005. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long-term follow-up was made to assess late prognosis. RESULTS Bioprostheses were involved in 52% of cases and mechanical valves in 48%. The aortic valve was affected in 45% of patients. Staphylococcus epidermidis was isolated in 23% of cases, Streptococcus spp in 21%, S aureus in 13%, and Enterococcus in 8%. Cultures were negative in 18% of cases. Twenty-six patients were treated medically and 107 with combined antibiotics and valve replacement. The operative mortality was 6.5% and the in-hospital mortality, 29%. Presence of an abscess at echocardiography, urgent surgical treatment, heart failure, thrombocytopenia, and renal failure were significant predictors of in-hospital death. Kaplan-Meier survival at 12 months was 42% in patients treated medically and 71% in those treated surgically (P = .0007). Freedom from endocarditis was 91% at the end of follow-up. CONCLUSIONS Prosthetic valve endocarditis is a serious condition with high mortality. Patients with perivalvular abscess had a worse prognosis, and combined surgical and medical treatment could be the preferred approach to improve outcome.

Everolimus-related pulmonary toxicity in heart transplant recipients.

Pulmonary toxicity (PT) is emerging as a frequent and serious complication of sirolimus, a proliferation signal inhibitor (PSI) used in solid-organ transplantation. Everolimus is a more recently developed PSI with molecular structure very similar to that of sirolimus. Surprisingly, although experience with everolimus is increasing and becoming substantial, there remains very little information about everolimus-related PT. Herein we report 2 heart transplant recipients who developed a non-infectious pulmonary syndrome after everolimus treatment was started. Transbronchial pulmonary biopsy specimens showed typical interstitial pneumonitis, and everolimus discontinuation resulted in rapid clinical and radiological improvement. Although PT seems to be more common after sirolimus exposure, everolimus is by no means spared from this potentially lethal complication and should always be suspected in the relevant clinical setting.

Plasma Levels of Transforming Growth Factor-β1 Reflect Left Ventricular Remodeling in Aortic Stenosis

Background TGF-β1 is involved in cardiac remodeling through an auto/paracrine mechanism. The contribution of TGF-β1 from plasmatic source to pressure overload myocardial remodeling has not been analyzed. We investigated, in patients with valvular aortic stenosis (AS), and in mice subjected to transverse aortic arch constriction (TAC), whether plasma TGF-β1 relates with myocardial remodeling, reflected by LV transcriptional adaptations of genes linked to myocardial hypertrophy and fibrosis, and by heart morphology and function. Methodology/Principal Findings The subjects of the study were: 39 patients operated of AS; 27 healthy volunteers; 12 mice subjected to TAC; and 6 mice sham-operated. Myocardial samples were subjected to quantitative PCR. Plasma TGF-β1 was determined by ELISA. Under pressure overload, TGF-β1 plasma levels were significantly increased both in AS patients and TAC mice. In AS patients, plasma TGF-β1 correlated directly with aortic transvalvular gradients and LV mass surrogate variables, both preoperatively and 1 year after surgery. Plasma TGF-β1 correlated positively with the myocardial expression of genes encoding extracellular matrix (collagens I and III, fibronectin) and sarcomeric (myosin light chain-2, β-myosin heavy chain) remodelling targets of TGF-β1, in TAC mice and in AS patients. Conclusions/Significance A circulating TGF-β1-mediated mechanism is involved, in both mice and humans, in the excessive deposition of ECM elements and hypertrophic growth of cardiomyocytes under pressure overload. The possible value of plasma TGF-β1 as a marker reflecting preoperative myocardial remodeling status in AS patients deserves further analysis in larger patient cohorts.

Avoidance of Calcineurin Inhibitors With Use of Proliferation Signal Inhibitors in De Novo Heart Transplantation With Renal Failure

BACKGROUND This study describes our experience with proliferation signal inhibitors in de novo heart transplant recipients with significant renal impairment. To circumvent further nephrotoxicity, calcineurin inhibitors were avoided in the peri-operative period. METHODS Immunosuppression in 20 patients was with a proliferation signal inhibitor (sirolimus, 14; everolimus, 6), an anti-mitotic drug, and corticosteroids from the time of transplantation. Induction was used in 9 patients (45%). All patients had preoperative significant renal dysfunction (mean glomerular filtration rate <30 ml/min/1.73 m(2)), and 4 patients required dialysis. RESULTS Post-operatively, the glomerular filtration rate significantly increased (>65 ml/min/1.73 m(2) at Month 1, remaining stable thereafter). No patients required dialysis after the first month of transplantation. Mean follow-up was 500 days. Rejection episodes occurred in 11 patients (55%), and 4 patients died (2 of rejection, although 1 death occurred 48 days after conversion to conventional treatment with tacrolimus). Half of the patients were eventually converted to conventional calcineurin-inhibitor therapy because of proliferation signal inhibitor adverse events. CONCLUSION Although this immunosuppressive approach was associated with a somewhat high rate of rejection and frequent side effects, it represents an attractive alternative in the complicated peri-operative setting of patients with significant renal impairment. This approach could serve as a temporary bridge to a conventional treatment.

Predictors of long-term renal function after conversion to proliferation signal inhibitors in long-term heart transplant recipients

BACKGROUND The purpose of this study was to evaluate the change in renal function and its determinants after replacement of calcineurin inhibitors with a proliferation signal inhibitor (sirolimus or everolimus) in long-term heart transplant recipients. METHODS We studied 49 consecutive patients in whom a switch to a proliferation signal inhibitor was carried out 9 ± 4 years after transplantation. Evolutive glomerular filtration rate was assessed at a mean of 28 months after conversion by the simplified MDRD equation. RESULTS Pre-conversion glomerular filtration rate (40 ± 22 ml/min/1.73 m(2)) remained stable at 1 year after conversion (41 ± 22 ml/min/1.73 m(2)), but decreased significantly by the end of follow-up (35 ± 22 ml/min/1.73 m(2); p = 0.008 and p = 0.002 vs pre-conversion and 1-year values, respectively). In a multivariate model, including age, time from transplantation to conversion, pre-conversion glomerular filtration rate, presence of diabetes and use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) therapy, the rate of decline in renal function was related only to the presence of diabetes (p = 0.017) and inversely related to the use of ACEI/ARB therapy (p = 0.003). There were no significant differences with respect to age, time between transplantation and replacement and baseline glomerular filtration rate. CONCLUSION In long-term heart transplant recipients, late substitution of a calcineurin inhibitor for a proliferation signal inhibitor does not preclude a decrease in renal function in the long-term setting. We identified the presence of diabetes as the main clinical predictor of renal function deterioration. In contrast, we found that the use of ACEI/ARB therapy could exert a protective effect.

Performance of 96 CarboMedics valve replacements in 75 patients less than twenty-one years of age☆

Valve replacement still represents a problem in the very young patient. Between July 1988 and November 1993, 96 CarboMedics mechanical valves were implanted in 75 patients with a mean age of 11.76 years (range, 5 months to 20 years). The mean preoperative New York Heart Association functional class was 3.2, and 89.3% of the patients were in sinus rhythm. The cause was rheumatic in 60%, congenital in 24%, and infective in 12%. Mitral valve replacement was undertaken in 43 patients, aortic in 11, and mitroaortic in 21. Among the 18 patients with congenital defects, 13 required simultaneous repair of their complex lesions. The hospital mortality was 12% (9 patients). Cause and age were significant factors responsible for mortality. The mortality was 27.8% for patients with congenital disease and 6.7% for those with rheumatic defects (p = 0.0365); it was 40% for patients younger than 2 years, 14.3% for those between 3 and 10 years old, and 5.9% for those older than 10 years (p = 0.0108). The maximum follow-up was 54 months (mean, 18 months). There were 10 late deaths (15.15%). No embolic events occurred. All patients were on anticoagulation therapy except 2 who were on antiaggregant therapy. One of them underwent successful reoperation for treatment of mitral prosthetic thrombosis. Three reoperations were performed: one for thrombosis, one for perivalvular leak, and one for endocarditis. The total actuarial survival was 68.19% +/- 7.02%. Freedom from embolism was 100%; from thrombosis, 96.72% +/- 3.22%; from severe hemorrhage, 94.94% +/- 3.67%, and from reoperation, 83.07% +/- 9.51%.

Cambios en el perfil de la endocarditis sobre válvula protésica en un hospital de tercer nivel: 1986-2005

Introduccion y objetivos. Estudiar la evolucion de las caracteristicas clinicas, la etiologia y el pronostico de la endocarditis sobre valvula protesica en un hospital de tercer nivel. Metodos. Estudio de cohortes retrospectivo de todos los pacientes diagnosticados de endocarditis sobre valvula protesica desde 1986 a 2005 segun los criterios de Duke modificados. Se analizaron dos periodos temporales: enero de 1986 a diciembre de 1995 (P1) y enero de 1996 a diciembre de 2005 (P2). Resultados. Se estudiaron 133 episodios en 122 pacientes. En 73 episodios (54,9%) la endocarditis fue diagnosticada en el P1 y en 60 (45,1%), en el P2 (incidencia del 2,19 y el 2,18% respectivamente). La edad, media ± desviacion estandar, fue de 52,6 ± 16,6 anos en el P1 y 66,2 ± 11,5 anos en el P2 (p = 0,0001). Las caracteristicas clinicas fueron similares en ambos periodos de estudio. Fue llamativo el incremento de infecciones por enterococo (el 12,5% en el P2 y el 4,9% en el P1; riesgo relativo [RR] = 2,5; intervalo de confianza [IC] del 95%, 0,7-9,6) asi como el descenso de las infecciones por estreptococos del grupo viridans (el 12,5% en el P2 y el 31,1% en el P1; RR = 0,4; IC del 95%, 0,2-0,9). Los pacientes intervenidos en el P1 fueron el 90,4% (63/73), mientras que en el P2 fueron el 68,3% (41/60), diferencias que resultaron estadisticamente significativas (RR = 0,8; IC del 95%, 0,6-0,9). La mortalidad intrahospitalaria fue del 28,8% en el P1 y el 30% en el P2 (RR = 1; IC del 95%, 0,6-1,7). Conclusiones. Durante los 20 anos de estudio, se ha observado un cambio en la epidemiologia y la etiologia microbiologica de la endocarditis sobre valvula protesica. El abordaje diagnostico y terapeutico tambien se ha modificado, aunque la mortalidad se ha mantenido elevada

Double aortic arch presents with dysphagia as initial symptom.

![Figure][1] A 62-year-old woman presented with breathlessness and dysphagia. Routine chest x-ray showed a widening in the upper mediastinum that suggested a thoracic aorta enlargement. No cardiomegaly was found (A) . Transthoracic echocardiography revealed normal left ventricular systolic

Electrocardiographic Diagnosis of Left Main Coronary Artery Obstruction Using ST-Segment and QRS-Complex Vector Analysis

INTRODUCTION AND OBJECTIVES It is vital that obstruction of the left main coronary artery (LMCA) is diagnosed early. We investigated the value of ST-segment and QRS-complex vector analysis in identifying LMCA obstruction in acute coronary syndrome. METHODS The study involved 57 consecutive patients with electrocardiographic features suggestive of LMCA obstruction. Both ST-segment and QRS-complex parameter vectors were analyzed. RESULTS Coronary angiography showed that the obstructed vessel was the LMCA in 20 patients, the left circumflex artery in 19, the right coronary artery in 10, and the left anterior descending artery in three. Five patients had three-vessel disease. An ST vector that was directed between -90 degrees and 180 degrees in the frontal plane was observed in 100% of patients with an LMCA obstruction (P< .001). The specificity of this observation was 78%. An ST vector directed anteriorly or parallel to the horizontal plane was present in 95% of patients (19/20) with an LMCA obstruction (P< .001; specificity 92%). A QRS vector with a left shift é-30 degrees was observed in 75% (15/20) with LMCA disease (P< .001; specificity 95%). An ST vector directed between -90 degrees and 180 degrees and anteriorly had a sensitivity of 95% and specificity of 100% for LMCA obstruction. An ST vector directed between -90 degrees and 180 degrees combined with a left QRS vector shift > or =-30 degrees had a sensitivity of 75% and a specificity of 100% for LMCA obstruction. A simple algorithm combining these observation was able to predict LMCA obstruction in 100% of patients. CONCLUSIONS In acute coronary syndrome, ST-segment and QRS-complex vector analysis can predict the presence of LMCA obstruction.