Andalusian registry of heart transplantation: first official adult heart transplant report 2010

This is the first official report of the Andalusian Registry of Heart Transplantation. Since 1986, two centers in the community have been authorized to perform adult heart transplantation. Until 2010, 854 adult heart transplantation procedures were performed, which constitute the basis of the present report. Clinical features and survival are analyzed. The leading reason for heart transplantation was ischemic cardiomyopathy (34%) and nonischemic dilated cardiomyopathy (34%). The mean age of the recipients was 46 ± 16 years and the mean age of the donors was 29 ± 13 years. After a median follow-up of 106 months, the mean survival was 13.4 ± 0.6 years.

[Influence of genetic variation at apoprotein A-1 gene promoter region on plasma lipid levels in heart transplantation patients]

BACKGROUND

To study if the presence of the G/A polymorphism at the apo A-I gene promoter region could determine the lipid profile in patients with hyperlipidemia after heart transplantation, or if it is related with the type of heart disease that determined the transplantation.

PATIENTS AND METHODS

This study included 31 patients with hyperlipidemia after heart transplantation. Anthropometric parameters, basic analytic and lipid study were measured in these subjects. Identification of the G/A mutation in the promoter region of the apo A-I gene was performed.

RESULTS

22 patients had the G/G genotype and 9 the G/A. 14 were transplanted by coronary heart disease and 17 by non ischemic heart disease. Patients with the A allele had higher cHDL (63 [SD 15] vs 53 [10]; p = 0.034) and apo A-I plasma levels (156 [34] vs 132 [24]; p = 0.040) than G/G subjects. The A allele was present in the 18% of the patients transplanted by ischemic heart disease and in the 43% of the transplanted by another etiology (p = 0.073).

CONCLUSIONS

The presence of the G/A genotype in the promoter region of the apo A-I gene determines higher plasma levels of cHDL in patients with hyperlipidemia after heart transplantation.

Lovastatin versus bezafibrate for hyperlipemia treatment after heart transplantation

BACKGROUND

Elevation in total and low-density lipoprotein cholesterol levels and a decrease in high-density lipoprotein cholesterol plasma concentrations are common in heart transplant recipients. The pathogenesis of this hyperlipemia after heart transplantation is complex. Currently available antilipemic agents are difficult to use because their adverse effects are potentiated by immunosuppressor treatment. The present investigation was carried out to test the safety and efficacy of lovastatin and bezafibrate in 18 patients with hyperlipemia after heart transplantation.

METHODS

In this crossover study, after 3 months of dietary recommendations, the subjects were randomly assigned to an 8-week period of lovastatin treatment (10 mg/day) followed by an additional 8-week period of treatment with bezafibrate (400 mg/day) or vice versa. The two treatments were separated by an 8-week washout period.

RESULTS

Both drugs reduced total and low-density lipoprotein cholesterol and apoprotein B concentrations. High-density lipoprotein cholesterol was only increased with bezafibrate. The total cholesterol/high-density lipoprotein cholesterol and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratios were decreased under both treatments, but these changes were greater with bezafibrate. Apo AI levels increased with lovastatin. Bezafibrate produced a rise in high-density lipoprotein cholesterol and reduced total and very low-density lipoprotein triglycerides and very low-density lipoprotein cholesterol. Both drugs decreased intermediate density lipoprotein cholesterol and triglyceride levels, but the effect of bezafibrate on intermediate-density lipoprotein triglycerides was significantly greater. The two drugs were well tolerated and liver enzymes, creatine kinase, and renal function remained stable.

Repetitive nontreated episodes of grade 1B or 2 acute rejection impair long-term cardiac graft function

BACKGROUND

Episodes of grade 1B or 2 acute heart rejection are usually not treated, and most of them resolve spontaneously.

METHODS

With the aim to assess long-term outcome in patients with repetitive nontreated episodes of low-grade (1B, 2) acute rejection, we have studied 141 heart transplant recipients in whom the evolutive pattern of acute rejection during the first 6 months after transplantation could be determined.

RESULTS

Forty-four patients (31%) had only grade 0 or 1A acute rejection episodes (pattern A); 23 patients (16%) had three or more episodes of grade 1B or 2 acute rejection without 3A or more advanced rejection (pattern B); 48 patients (34%) had one or two episodes of grade 3A, 3B, or 4 acute rejection only during the first 6 months after transplantation (pattern C); and 26 patients (19%) had three or more episodes of grade 3A, 3B, or 4 acute rejection (pattern D). Overall mortality was 11%, 26%, 19%, and 46% for patients with patterns A, B, C, and D, respectively. No difference was found among patterns with regard to incidence of graft atherosclerosis. Left ventricular ejection fraction at 1 year after transplantation was significantly lower (p < 0.05) for patients with pattern B (50% +/- 5% versus 59% +/- 7%, 59% +/- 11%, and 56% +/- 6% for patterns A, C, and D, respectively); cardiac index also was lower for patients with pattern B than for those with pattern A (3.6 +/- 0.6 versus 4.1 +/- 0.6 L/min/m2, p < 0.05).

CONCLUSIONS

Although mortality was higher for patients with more severe episodes of acute rejection, only repetitive nontreated episodes of grade 1B or 2 rejection significantly impaired long-term graft function.

[The echocardiographic findings in patients with brain death. The implications for their selection as heart transplant donors]

INTRODUCTION AND AIMS

Brain death causes myocardial impairment by some mechanisms not yet well understood. The aim of this work was to assess the echocardiographic features found in these patients and their implication in donor selection for heart transplantation.

METHODS

With this aim, we have studied 38 consecutive patients with brain death assessed as possible donors for heart transplant in our hospital in the last 3 years. Age was 23 +/- 13 years; 77% were male. No history of cardiac disease was present in any patient. An adequate transthoracic echocardiogram was obtained in 74% of patients; transesophageal view was used in the remaining 26%.

RESULTS

Echocardiogram was strictly normal in only 14 patients (37%). Mild valvular alterations were found in 5 patients (13%); a dilated aortic root in 1 (3%); moderate concentric left ventricular hypertrophy in 5 (14%); mild pericardial effusion in 1 (3%); mild septal hypokinesia with normal left ventricular ejection fraction in 4 (10%); abnormal left ventricular diastolic function in 7 (18%); and diffuse hypokinesia with ejection fraction less than 60% in 14 (37%). In 7 patients (18%) ejection fraction was lower than 40% (one of them was cocaine-addict). Mean ejection fraction was 59 +/- 15% (23 to 83%). Only 2 of the 19 (10%) donor hearts implanted in our hospital showed early dysfunction after transplant, but no relation to pretransplant ejection fraction was found. Ejection fraction increased from 62% pretransplant to 73% at one week after transplant in the other 17 cases.

CONCLUSIONS

Brain death commonly causes alterations of left ventricular function, and this impairment is severe in almost 20% of cases. These echocardiographic features must be known when selection of donors for heart transplantation is concerned.

Visceral Kaposi's sarcoma without mucocutaneous involvement in a heart transplant recipient

Kaposi's sarcoma has been occasionally reported in heart transplant recipients, but its occurrence without mucocutaneous involvement is extremely rare. In these uncommon cases, the tumor can be indistinguishable from opportunistic infections, making diagnosis difficult. The case of a patient in whom visceral Kaposi's sarcoma was diagnosed by necropsy 6 months after heart transplantation is reported.

Influence of heart transplantation on the natural history of patients with severe congestive heart failure

In an attempt to study the influence of heart transplantation on the natural history of patients with severe congestive heart failure, we have reviewed our experience with 240 consecutive patients who were New York Heart Association class IV or III/IV, who had left ventricular ejection fraction less than 35%, who were younger than 65 years of age, and who were assessed for heart transplantation in our hospital since May 1986. Mean age was 47 +/- 12 years. Left ventricular ejection fraction was 20% +/- 6%. Eighty-seven percent were male. New York Heart Association class was IV in 88% and III/IV in 12%. The cause was ischemic heart disease in 35% of patients, valvular heart disease in 13% of patients, and primary dilated cardiomyopathy in 52% of patients. At initial assessment, heart transplantation was considered to be not indicated in 30% of patients, indicated in 51% of patients, and contraindicated in 19% of patients. During a follow-up of 13 +/- 13 months (2 to 64 months), 110 patients underwent transplantation (46%). Posttransplantation actuarial probability of survival was 70% at 3 years. Three-year probability of survival free from transplantation was significantly lower for patients older than 55 years of age (p < 0.05), for those with left ventricular ejection fraction less than 20% (p < 0.05), ischemic causes (p < 0.05), New York Heart Association class IV (p < 0.001), and indication/contraindication for transplantation (p < 0.001); no difference was noted for gender.(ABSTRACT TRUNCATED AT 250 WORDS)

[Patients with an acute myocardial infarct treated in a coronary unit or in a general cardiology ward A comparative study]

INTRODUCTION AND OBJECTIVES

Coronary care units have been accepted as the standard location for treatment for patients with acute myocardial infarction. Nevertheless, controversy over their clinical impact, current role and cost-effectiveness still remains. Due to the increased incidence of coronary artery disease in Spain, coronary care units are often full, and patients with acute myocardial infarction must be cared for in a general cardiology ward.

METHODS

We have studied the features and results of 420 patients with acute myocardial infarction consecutively admitted to our hospital and compared patients cared for in the coronary care unit (329 [78%]) with those cared for in the cardiology ward (91 [22%]). Admission to cardiology ward or coronary care unit was based on the clinical judgment of emergency room physicians and the bed availability. No differences in age, sex, risks factors, prior history of coronary heart disease, blood pressure on admission, extension and complications of myocardial infarction were found between both groups.

RESULTS

The percentage of patients with evolved and non-Q wave acute myocardial infarction, and admission electrocardiogram not suggestive of infarction was significantly higher in ward group (23 versus 2.4%, p < 0.001; 19 versus 11%, p < 0.01; and 43 versus 15%, p < 0.01; respectively). Although patients admitted to the coronary care unit underwent intravenous thrombolysis and coronary artery revascularization procedures in a higher proportion, mortality was similar in both groups (14% for ward patients and 17% for coronary care unit patients). When patients with evolved or non-Q wave infarctions and those with admission electrocardiograms not suggestive of infarction were excluded from the analysis, mortality rates remained similar. Subgroups mortality was in general similar for patients cared for in cardiology ward or in coronary care unit, although patients without shock, with Killip class I or II, and older than 70 years, had a slightly lesser mortality when treated in the Cardiology ward (5 versus 11%, 6 versus 11%, and 14 versus 28%, respectively). By contrast, patients with shock, Killip class III or IV, and electrocardiogram at admission not suggestive of infarction, had a lesser mortality when cared for in coronary care unit.

CONCLUSIONS

We conclude that some subgroups of patients with acute myocardial infarction can be, if needed, effective and safely cared for in cardiology ward.

A randomized study comparing deflazacort and prednisone in heart transplant patients

Prednisone is widely used by most heart transplantation units despite its frequent side effects. Deflazacort, an oral synthetic steroid with fewer side effects, has been successfully used in patients after heart transplantation, but a prospective study comparing deflazacort and prednisone in transplant patients is lacking. We have carried out, in the last year, a prospective trial of deflazacort versus prednisone involving 35 consecutive heart transplant patients. Two of these patients died perioperatively (surgical mortality, 5.7%), and another two were excluded from the protocol because of diabetes mellitus in one patient and active infection before transplantation in the other patient. Thus 31 patients were enrolled in the 3-month study. All of them were treated with antithymocyte globulin, 10 mg/kg/day for 3 days after transplantation, azathioprine, and cyclosporine; patients were randomly assigned groups: 15 patients to receive deflazacort therapy, 1.5 mg/kg/day, and 16 patients to receive prednisone therapy, 1 mg/kg/day, starting the first day after transplantation. Steroids were rapidly tapered, reaching the maintenance dose at 2 to 3 weeks after transplantation (prednisone, 0.15 mg/kg/day; deflazacort, 0.25 mg/kg/day). Both groups were similar in terms of age, gender, ABO identity, serum cyclosporine levels, azathioprine dosage, and pretransplantation serum glucose and lipids levels. Seven endomyocardial biopsies were performed on each patient, at 1, 2, 3, 5, 7, 10, and 13 weeks after transplantation. Incidence of acute rejection was similar between prednisone and deflazacort groups; 33% of patients receiving prednisone therapy and 42% of patients receiving deflazacort therapy had one episode of 3A or higher rejection (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

[Brucellar pericarditis: 2 different forms of presentation for an unusual etiology]

Two cases of Brucella melitensis pericarditis are reported. Pericardial involvement was the first and almost only manifestation of brucellosis in the first patient while in the second, a significant pericardial effusion was discovered on a routine echocardiogram performed in a patient with clinically florid brucellosis. Some etiopathogenic aspects of this uncommon etiology are discussed.

[Acute myocardial infarct in persons over 70. The results and differential characteristics]

Distinctive features of patients over 70 years with acute myocardial infarction (AMI) are studied. Between May 1988 and April 1989, 420 patients with AMI were admitted to our hospital; 118 of them (28.5%) were older than 70 years. In this group of patients, proportion of woman was higher (36 vs 16%, p less than 0.001), while incidence of smoking and hypercholesterolemia was lower (41 vs 64%, p less than 0.001; and 15 vs 29%, p less than 0.05). There was no differences in other risk factors, prior history of coronary heart disease (angina, AMI, coronary surgery), or general features of AMI (location, proportion of painless AMI, non-Q-wave AMI, evolved AMI, initial admission to coronary care unit or general ward, time from the beginning of symptoms to admission, residual ejection fraction). The incidence of severe complications was superior between older patients: shock, 17 vs 7% (p less than 0.05); Killip class III/IV, 30 vs 13% (p less than 0.001); and fascicular blocks: 26 vs 16% (p less than 0.05). Hospital mortality was also higher in older patients, 25.5 vs 14% (p less than 0.01). No patients older than 70 years received fibrinolytic therapy, and only one underwent coronary artery surgery (22% and 15%, respectively, in younger patients). Coronary arteriography, exercise test, radionuclide ventriculography and Holter monitoring were also performed before discharge in a lesser proportion in older patients. We conclude that mortality and severe complications were higher between patients over 70 years with AMI. We think that mortality could be decreased by a more aggressive management in, at least, selected groups of older patients with AMI.

[Digitalis poisoning from medicinal herbs. Two different mechanisms of production]

Two cases of digitalis toxicity due to uncontrolled ingestion of medicinal herbs are presented. The first of them was caused by oleander (Nerium oleander); digoxinemia levels were very high in this patient (4.44 ng/l), who presented many brady- and tachyarrhythmias. These arrhythmias disappeared when digoxinemia returned to normal values. The second patient had atrial fibrillation with slow ventricular rate, severe hypokalemia (2.1 mEq/l) and normal digoxinemia levels. He was taking medicinal herbs for a cold, with sorbitol between its components. Sorbitol may be similar to mannitol and glycerol (osmotic diuretic drugs) when taken at high doses. Uncontrolled ingestion of medicinal herbs is not safe, and severe poisoning can occur.