Santiago Serrano-Fiz

RADIAL: A novel primary graft failure risk score in heart transplantation

BACKGROUNDnPrimary graft failure (PGF) is the leading cause of early mortality after heart transplantation (HT). Our aim is to propose a working definition of PGF and to develop a predictive risk score.nnnMETHODSnPGF was defined by four criteria reflecting significant myocardial dysfunction, severe hemodynamic impairment, early onset after HT, and absence of secondary causes of graft dysfunction. We identified independent risk factors for PGF in a derivation series of 621 HTs and constructed a predictive model. After proving its internal consistency we tested the model in a prospective validation series.nnnRESULTSnThe incidence and lethality of PGF in our series were 9% and 80%, respectively. We identified 6 multivariate risk factors for PGF (Right atrial pressure ≥ 10 mm Hg, recipient Age ≥ 60 years, Diabetes mellitus, Inotrope dependence, donor Age ≥ 30 years, Length of ischemic time ≥ 240 minutes--i.e., RADIAL). Analysis of isolated right ventricular failure showed similar predictors. The RADIAL score was obtained by adding 1 point for each of these factors present in a given HT. PGF incidence increased significantly as the RADIAL score increased (p < 0.001 for trend). Rates of actual and predicted PGF incidence for RADIAL subgroups showed a good correlation (C-statistic = 0.74). In a prospective validation cohort, RADIAL score kept its predictive ability.nnnCONCLUSIONSnPGF as defined by these criteria showed a high impact on early post-HT mortality in our series. The RADIAL score showed good ability to predict the development of PGF, and could be useful in the prevention and early treatment of this complication.

Clinical experience with retrograde lung preservation

Abstractu2002 Previous reports and our own experimental work suggest increased vascularity of the tracheo‐bronchial wall when retrograde lung preservation is used. This principle was clinically applied in 21 consecutive lung transplant recipients (10 single and 11 bilateral). Lung preservation was achieved via the left atrial appendage and drainage was obtained through the pulmonary artery. Pneumoplegic preservation was achieved with modified Euro‐Collins solution. Cardioplegia was induced by the standard method and the heart, harvested by different teams, did not exhibit left ventricular dilatation. Thirty‐two bronchial anastomoses without wrapping were performed. No primary lung graft failure was documented. Cardiopul‐monary bypass was instituted in three cases of pulmonary hypertension; however, this was deemed unnecessary in the remainder of the cases of bilateral transplantation while the second organ was being implanted. All bronchial anastomoses were followed between 2 and 28 months. A single instance of bronchial anastomosis dehiscence was observed on the 30th postoperative day. However, no stents were employed in this series, and no strictures or anastomotic granulomas have been reported so far. All the hearts could be used satisfactorily except for one primary graft failure. In conclusion, retrograde lung preservation is feasible in clinical lung transplantation, with simultaneous harvesting of the heart. The impact of retrograde lung preservation on the late clinical outcome remains to be seen.

Preservación bifásica del injerto en el trasplante pulmonar

El metodo de preservacion estandar mas utilizado en el trasplante pulmonar es la infusion de solucion pulmoplejica a traves de la arteria pulmonar (AP). El presente estudio prospectivo analiza la funcion inicial del injerto pulmonar y cardiaco cuando se utiliza una perfusion pulmonar bifasica, retrograda a traves de la auricula izquierda (AI) y anterograda a traves de la AP. Se evaluaron 26 injertos cardiacos y pulmonares (9 unilaterales y 17 bilaterales), entre enero de 1996 y marzo de 1997, preservados mediante cardioplejia y pulmoplejia (bifasica). Los indicadores de la viabilidad del injerto recogidos fueron: la relacion de la presion arterial de oxigeno (PaO 2 ) con la fraccion inspirada (FiO 2 ), la presion media sistemica (PSM), la presion media de la arteria pulmonar (PAPM), el gasto cardiaco (GC), las resistencias vasculares pulmonares (RVP) y las resistencias vasculares sistemicas (RVS). Estos parametros se obtuvieron al ingreso en la unidad de cuidados intensivos y en las primeras 24xa0h. Asi mismo, se realizo un seguimiento de un mes de los trasplantes cardiacos, evaluando la morbimortalidad. Tras el trasplante, la mayoria de los pacientes presentaban un cociente de oxigenacion (PaO 2 /FiO 2 ) mayor de 252xa0mmHg en las primeras 48xa0h. Los parametros hemodinamicos tambien se mantuvieron en cifras normales tras la cirugia y 24xa0h mas tarde. El tiempo medio de isquemia fue de 245xa0min para los trasplantes unilaterales, 215 para el primer pulmon en los bipulmonares y 300xa0min para el segundo. Tres pacientes presentaron en el postoperatorio inmediato disfuncion del injerto pulmonar y fueron tratados satisfactoriamente con oxido nitrico (ON). Ninguno de los pacientes con trasplante cardiaco presento fallo cardiaco primario o dilatacion del ventriculo izquierdo. Concluimos que la preservacion pulmonar bifasica consigue una viabilidad funcional inicial del injerto satisfactoria. Los injertos cardiacos extraidos simultaneamente presentaron una buena funcion en el paciente sometido a trasplante sin precisar aporte farmacologico o mecanico.

Influence of hypothermia on right atrial cardiomyocyte apoptosis in patients undergoing aortic valve replacement

BackgroundThere is increasing evidence that programmed cell death can be triggered during cardiopulmonary bypass (CPB) and may be involved in postoperative complications. The purpose of this study was to investigate whether apoptosis occurs during aortic valve surgery and whether modifying temperature during CPB has any influence on cardiomyocyte apoptotic death rate.Methods20 patients undergoing elective aortic valve replacement for aortic stenosis were randomly assigned to either moderate hypothermic (ModHT group, n = 10, 28°C) or mild hypothermic (MiHT group, n = 10, 34°C) CPB. Myocardial samples were obtained from the right atrium before and after weaning from CPB. Specimens were examined for apoptosis by flow cytometry analysis of annexin V-propidium iodide (PI) and Fas death receptor staining.ResultsIn the ModHT group, non apoptotic non necrotic cells (annexin negative, PI negative) decreased after CPB, while early apoptotic (annexin positive, PI negative) and late apoptotic or necrotic (PI positive) cells increased. In contrast, no change in the different cell populations was observed over time in the MiHT group. Fas expression rose after reperfusion in the ModHT group but not in MiHT patients, in which there was even a trend for a lower Fas staining after CPB (p = 0.08). In ModHT patients, a prolonged ischemic time tended to induce a higher increase of Fas (p = 0.061).ConclusionOur data suggest that apoptosis signal cascade is activated at early stages during aortic valve replacement under ModHT CPB. This apoptosis induction can effectively be attenuated by a more normothermic procedure.

Failure of Percutaneous Closure of Prosthetic, Aortic Paravalvular Leak

We report the progression of aortic insufficiency after percutaneous closure of an aortic prosthesis paravalvular leak with the Amplatzer vascular plug (AGA Inc, Golden Valley, MN). Removal of the device and replacement of the aortic prosthesis was successfully performed. Based on operative findings, we hypothesize that shape mismatch between the occluder system and the leak might promote tearing at the end of slanted defects further enhancing the regurgitant area.

Reparación valvular en la insuficiencia mitral crónica

La reparacion valvular es el tratamiento quirurgico ideal de la insuficiencia mitral. En este trabajo presentamos los resultados de la reparacion valvular en pacientes con insuficiencia mitral cronica operados en nuestro centro durante los ultimos 8 anos. Analizamos el grado de correccion de la insuficiencia, el beneficio funcional, la morbimortalidad hospitalaria, la evolucion posquirurgica de la funcion ventricular y la supervivencia global y libre de reoperacion a medio plazo.

Left atrial thrombosis after heart transplantation

Left atrial thrombosis in the absence of rheumatic heart disease and atrial fibrillation is a rare occurrence. We report two cases of left atrial pedunculated thrombus formation after orthotopic heart transplantation. Despite an uneventful post-operative course, sinus rhythm and normal contractility of the heart, large thrombi could be found several months following transplantation. Surgical thrombectomy was performed under cardiopulmonary bypass. Operative technique is proposed as one of the main factors that can contribute to left atrial thrombosis after heart transplantation.

Vibration and Staccato Flow Pattern in Ventricular Assist Devices

A patient awaiting a heart transplant may need a ventricular assist device (VAD) to stabilize the clinical situation as needed, and may even be discharged. These VADs have complicated mechanics and dysfunctions can occur, sometimes related to an obstruction in the entrance cannula (EC). We present the case of a 28-year-old man with dilated-phase hypertrophic cardiomyopathy who received a Berlin Heart Excor VAD. On the tenth day after the operation, following an intense negative balance, the EC started to vibrate and there were signs that the artificial ventricle was not filling up correctly. The echocardiogram showed that the left ventricular cavity was smaller than in other studies. The color Doppler study showed a PISA effect (Fig. 1A) in the EC of the left ventricular apex (Fig. 2). The Doppler continued showing high-flow velocity in the EC with intermittent unsteady flow, coinciding with the vibration (Fig. 1B), which were indicative of an obstruction. The vibration reduced once the patient was properly hydrated, and no clinical repercussions occurred. After 111 days on VAD support, 90 of those days at home, the patient received the heart transplant. The extracted heart showed that the EC opening was very close to a prominent papillary muscle (Fig. 3). The implant was close to the deformed papillary muscle and the ventricular diameter reduced over time, which could have contributed to the obstruction. This last point explains that the alteration was manifested days after the VAD was implanted, and improved when the patient was properly hydrated. PM A B 6 m/s

Trasplante cardiopulmonar: experiencia de 8 años en nuestro centro

Introduccion El trasplante cardiopulmonar es un tratamiento quirurgico reservado a pacientes candidatos a trasplante cardiaco o pulmonar que tienen de forma concomitante una grave enfermedad pulmonar o cardiaca, respectivamente. Material y metodos Se han analizado retrospectivamente los trasplantes cardiopulmonares realizados en nuestro centro desde el inicio del programa. Resultados Se realizaron en total 19 trasplantes cardiopulmonares desde 1998-2006, tres de ellos de caracter urgente. La edad media de los pacientes fue de 33 anos. La enfermedad que indico el trasplante fue hipertension pulmonar primaria en cinco casos (26%), sindrome de Eisenmenger en cuatro (21%), sindrome toxico en tres (16%), cardiopatia congenita compleja con hipertension pulmonar en tres, fibrosis quistica mas miocardiopatia dilatada en dos (11%), asi como un caso de miocardiopatia restrictiva con hipertension pulmonar grave (5%) y otro de cardiopatia isquemica mas fibrosis pulmonar. La mortalidad hospitalaria fue del 52%, debido a fallo multiorganico, sepsis de origen pulmonar y shock hemorragico postoperatorio. Tras la fase hospitalaria hubo dos muertes en el seguimiento. La probabilidad de supervivencia al ano y a los 5 anos fue del 45 y el 27%, respectivamente. Hasta la fecha continuan vivos siete pacientes (37%), todos ellos en buena situacion funcional. Conclusiones En nuestra limitada experiencia el trasplante cardiopulmonar es un procedimiento complejo con una indudable mortalidad precoz. La supervivencia a corto y medio plazo es buena, y los pacientes que superan la fase hospitalaria experimentan una franca mejoria funcional.

Surgical Treatment for Hypertrophic Obstructive Cardiomyopathy

Introduction and objectives Five percent of the patients with hypertrophic obstructive cardiomyopathy (HOCM) have symptoms unresponsive to medical treatment and are candidates for invasive therapy. The objective of this study was to analyze our results with surgical treatment of HOCM during the last 10 years. Patients and method Between July 1993 and January 2004u200826 patients with HOCM refractory to drug therapy were operated on. An extended septal myectomy was performed, in combination with anterior mitral leaflet plication in 19 cases (73%) and with mitral valve replacement in 5 (19%). Evolution of the grade of dyspnea, left ventricle outflow tract gradient (LVOTG), mitral regurgitation, and systolic anterior motion after surgery was analyzed. Results Mean follow-up was 63 (37) months. After surgery, a significant reduction in LVOTG (from 96.5 to 19.5 mmHg; P P P Conclusions Surgery in patients with HOCM yields great clinical improvements with low morbidity and mortality. Simultaneous intervention for both myocardial and valvular components of the disease allows not only reduction in the LVOTG but also correction of mitral regurgitation and abolition of systolic anterior motion.