Association of the Surgical Technique With the Structural Valve Deterioration of a Bioprosthesis: A Prospective Cohort Study

The Trifecta aortic valve is a prosthesis with externally mounted leaflets and a stent which may be deformed during implant. Our aim was to know if the use of the holder as a protection device during the knotting has an impact on the incidence of structural valve deterioration (SVD) or endocarditis. Prospective cohort study where all patients who underwent aortic valve replacement with a Trifecta aortic valve between 2013 and 2018 were included. The use of the holder as a protection device was collected in a database. Propensity-score matched methods were used and analyses were based on competing events. Death without SVD or prosthesis replacement not due to SVD was considered competing events. 782 patients were included, 352 pairs after the matching. Rates of SVD at 5 and 8 years were 5.8% (95% CI 3.5-8.7) and 13.6% (95% CI 9.2-18.9) in the group without holder and 2.3% (95% CI 1-4.5) and 7% (95% CI 4.2-10.8) in the group with holder; sHR = 0.49 (95% CI 0.27-0.86; P = 0.015). The risk of endocarditis at 8 years was 4.8% (95% CI 2.8-7.4) in the group without holder and 2.3% (95% CI 1.1-4.3) in the group with holder, sHR = 0.49 (95% CI 0.21-1.15, P = 0.1). The use of holder as a protection device during the knotting of the Trifecta aortic valve is associated with less risk of SVD.

A persistent ultraviolet outflow from an accreting neutron star binary transient

All disc-accreting astrophysical objects produce powerful disc winds. In compact binaries containing neutron stars or black holes, accretion often takes place during violent outbursts. The main disc wind signatures during these eruptions are blue-shifted X-ray absorption lines, which are preferentially seen in disc-dominated 'soft states'^1,2. By contrast, optical wind-formed lines have recently been detected in 'hard states', when a hot corona dominates the luminosity³. The relationship between these signatures is unknown, and no erupting system has as yet revealed wind-formed lines between the X-ray and optical bands, despite the many strong resonance transitions in this ultraviolet (UV) region⁴. Here we report that the transient neutron star binary Swift J1858.6-0814 exhibits wind-formed, blue-shifted absorption lines associated with C IV, N V and He II in time-resolved UV spectroscopy during a luminous hard state, which we interpret as a warm, moderately ionized outflow component in this state. Simultaneously observed optical lines also display transient blue-shifted absorption. Decomposing the UV data into constant and variable components, the blue-shifted absorption is associated with the former. This implies that the outflow is not associated with the luminous flares in the data. The joint presence of UV and optical wind features reveals a multi-phase and/or spatially stratified evaporative outflow from the outer disc⁵. This type of persistent mass loss across all accretion states has been predicted by radiation-hydrodynamic simulations⁶ and helps to explain the shorter-than-expected duration of outbursts⁷.

Regulation of black-hole accretion by a disk wind during a violent outburst of V404 Cygni

Accretion of matter onto black holes is universally associated with strong radiative feedback and powerful outflows. In particular, black-hole transients have outflows whose properties are strongly coupled to those of the accretion flow. This includes X-ray winds of ionized material, expelled from the accretion disk encircling the black hole, and collimated radio jets. Very recently, a distinct optical variability pattern has been reported in the transient stellar-mass black hole V404 Cygni, and interpreted as disrupted mass flow into the inner regions of its large accretion disk. Here we report observations of a sustained outer accretion disk wind in V404 Cyg, which is unlike any seen hitherto. We find that the outflowing wind is neutral, has a large covering factor, expands at one per cent of the speed of light and triggers a nebular phase once accretion drops sharply and the ejecta become optically thin. The large expelled mass (>10(-8) solar masses) indicates that the outburst was prematurely ended when a sizeable fraction of the outer disk was depleted by the wind, detaching the inner regions from the rest of the disk. The luminous, but brief, accretion phases shown by transients with large accretion disks imply that this outflow is probably a fundamental ingredient in regulating mass accretion onto black holes.

Neurobehavioral development of preterm and full term children: biomedical and environmental influences

BACKGROUND

Previous studies indicate that VLBW preterm children obtain significantly lower scores than full-term children in all the NBAS clusters. However the samples studied usually presented additional medical complications.

AIMS

The present study aims to compare the results obtained by low-risk preterm and full term children in the NBAS, and relate possible differences to biological and contextual factors.

METHOD

Early neurobehavioral development of 150 preterm (PR) children is compared to that of 49 full term children (FT). The children were assessed at the age of 15 days (corrected age for preterm children) with the NBAS. Biological and environmental variables were collected through an extended interview with the mothers as well as medical data.

RESULTS

Significant differences were found between preterm and full term children in the following areas: motor, range of state, and regulation of state. Differences were also found in relation to birth weight in these same three areas, following a parallel pattern. These differences between the two groups were not, however, necessarily more favorable for the FT group; the PR group had higher results in the motor and range of state areas, and lower results in the regulation of state area. The mothers' smoking habit had a negative effect on infants' regulation and orientation.

CONCLUSIONS

No general maturation delay in this particular sample of preterm children was found.

Application of System Dynamics technique to simulate the fate of persistent organic pollutants in soils

Persistent organic pollutants (POPs) are within the most dangerous pollutants released into the environment by human activities. Due to their resistance to degradation (chemical, biological or photolytic), it is critical to assess the fate and environmental hazards of the exchange of POPs between different environmental media. System Dynamics enables to represent complex systems and analyze their dynamic behavior. It provides a highly visual representation of the structure of the system and the existing relationships between the several parameters and variables, facilitating the understanding of the behavior of the system. In the present study the fate of γ-hexachlorocyclohexane (lindane) in a contaminated soil was modeled using the Vensim® simulation software. Results show a gradual decrease in the lindane content in the soil during a simulation period of 10 years. The most important route affecting the concentrations of the contaminant was the biochemical degradation, followed by infiltration and hydrodynamic dispersion. The model appeared to be highly sensitive to the half-life of the pollutant, which value depends on environmental conditions and directly affects the biochemical degradation.

Investigating a high ozone episode in a rural mountain site

A very high ozone episode with observed hourly values above 350 μg m(-3) occurred in July 2005 at the Lamas d'Olo air quality monitoring station, located in a mountainous area in the north of Portugal. Aiming to identify the origin and formation of this ozone-rich episode, a statistical analysis and a modelling approach were applied. A cross-spectrum analysis in the frequency domain and a synoptic analysis of the meteorological and air quality time series were performed. In order to go further in this analysis, a numerical modelling approach was applied. The results indicate that the transport of ozone and its precursors is the main responsible for the high ozone concentrations. Together with the local mountain breeze and subsidence conditions, the sea-breeze circulation transporting pollutants from the coastal urban and industrialized areas that reach the site during late afternoon turn out to be the driving forces for the ozone peaks.

Behavior of the pulmonary autograft in systemic circulation after the Ross procedure

OBJECTIVE

The purpose of this study was to evaluate performance in systemic circulation following pulmonary autograft aortic root replacement by means of serial postoperative echocardiographic studies.

METHODS

From November 1997 to November 1999, 30 patients (21 males, 9 females) with a mean age of 29.97 +/- 12.97 years (age range 6-54 years) underwent pulmonary autograft aortic root replacement. Seven of these patients (23.33%) were less than 15 years old. Postoperative echocardiographic measurements of the neo-aortic root were performed within three months of operation, at six months, one year, and annually thereafter. Analysis of this study includes 22 patients with at least three months of follow-up.

RESULTS

Operative mortality was 0%. Compared with preoperative values, the mean autograft annulus diameter exhibited an increase of 8.44% in the first month (1.44 +/- 0.22 cm/m2 vs. 1.55 +/- 0.21 cm/m2, p = 0.0101). An additional aortic annular dilation of 11.33% from baseline preoperative values was observed within the first year (1.41 +/- 0.15 cm/m2 preoperatively vs. 1.57 +/- 0.22 cm/m2, p = 0.0449). After the immediate postoperative period, the pulmonary autograft seemed to adapt to systemic circulation, and there were no differences in aortic annular size between 1-3 months after surgery and the 18-21 month follow-up period (1.60 +/- 0.18 cm/m2 vs. 1.60 +/- 0.27 cm/m2, n = 10). Diameter increase was not associated with the presence of aortic regurgitation. Mean neo-aortic maximal gradient was 7.85 +/- 5.59 mm Hg (3-29 mm Hg). There was a significant decrease in left ventricular size three months after surgery (50.71 +/- 10.20 mm preoperatively vs. 44.98 +/- 7.29 mm, p = 0.0491 in aortic stenosis patients and 68.50 +/- 8.39 mm vs. 59.04 +/- 9.21 mm, p = 0.0017 in aortic insufficiency patients).

CONCLUSIONS

Pulmonary autograft annulus increases up to the first year after the Ross procedure but does not appear to progress beyond that time. The pulmonary autograft allows optimal hemodynamic performance without causing substantial aortic regurgitation, thereby permitting normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

[Aortic valve replacement with pulmonary autograft (the Ross procedure) in adult and pediatric patients]

Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180-620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 +/- 12.6 years. Five patients were pediatrics (<= 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (>= grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 +/- 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 +/- 32 a 95.8 +/- 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significantly, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our series, are excellent after the Ross procedure.

Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation)

BACKGROUND AND AIM OF THE STUDY

Aortic valve replacement (AVR) with a pulmonary autograft is an alternative treatment for young patients with aortic valve disease. Superior hemodynamic performance of the pulmonary autograft, and impact on parameters of left ventricular function were analyzed.

METHODS

Thirty patients (21 males, nine females; mean age 29.97+/-12.29 years; range: 6-54 years) underwent a Ross procedure between November 1997 and November 1999. Seven patients (23%) were children (aged <15 years). In total, 22 patients were analyzed; each had at least three months follow up. Eleven patients had predominant aortic stenosis (AS), and 11 had aortic insufficiency (AI).

RESULTS

There were no operative deaths. Two patients developed severe insufficiency, and the autograft was replaced with a mechanical valve. Pre- and postoperative echocardiograms were reviewed. The mean neoaortic maximal gradient was 7.85+/-5.59 mmHg (range: 3-29 mmHg). AS patients showed reduced interventricular septal (IVS) thickness at one month (from 13.27+/-3.69 to 11.60+/-2.44 mm; p = 0.0165) and 18 months after surgery (p = 0.0104). Left ventricular posterior wall (LVPW) thickness was reduced from 12.04+/-3.75 to 9.48+/-2.47 mm (p = 0.0338) at one month and 18 months (p= 0.0128) after surgery. The left ventricular end-diastolic internal dimension (LVIDd) decreased from 50.71+/-10.20 to 44.98+/-7.29 mm (p = 0.0491) at one month after surgery. In AI patients, LVPW and IVS thicknesses showed no significant variation, and LVIDd was decreased at one month (from 68.50+/-8.39 to 59.04+/-9.21 mm; p = 0.0017) and 18 months (p = 0.0229) after surgery. Left ventricular end-systolic internal dimension (LVIDs) decreased from 44.06+/-6.39 to 39.03+/-7.99 mm (p = 0.0081) at three months after surgery. Left ventricular mass index (LVMI) in the AS group decreased from 179.01+/-62.26 to 115.74+/-37.62 g/m2 (p = 0.0021) at one month after surgery, and at 18 months was normal, with a decrease from 208.77+/-32.89 to 95.89+/-28.82 g/m2 (p= 0.0003) (n = 5). In the AI group, LVMI decreased from 186.25+/-85.21 to 140.58+/-62.02 g/m2 (p = 0.0011) at one month after surgery, and at 18 months from 217.70+/-98.02 to 146.73+/-84.55 g/m2 (p= 0.0131) (n = 5).

CONCLUSION

The pulmonary autograft procedure can be used safely to replace the aortic valve, and allows optimal hemodynamic performance, with no significant aortic regurgitation. The Ross procedure results in normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

[Aortic valve replacement with a pulmonary autograft (the Ross operation) in adult and pediatric patients. A preliminary study]

INTRODUCTION AND OBJECTIVES

Aortic valve replacement with the patients own pulmonary autograft (the Ross procedure) is by now, the best surgical method for the replacement of the diseased aortic valve in certain groups of patients, this is particularly true for young adults and children or neonates with complex left ventricular outflow tract obstructions. The procedure was described by Donald Ross in 1967, and many years have passed. So in view of the accumulated experience the indications have extended to a wide group of patients which include children, neonates and young adults with formal contraindications for anticoagulation. In this publication we present our experience and our preliminary results in a group of fifteen patients which include adult and pediatric.

MATERIAL AND METHODS

In six patients the etiology of lesion was congenital and in the remainder nine the valve had an acquired lesion. Two patients had an open heart procedure before this operation both of them to relieve an obstruction to the left ventricular outflow tract. In this group of patients the Ross procedure was carried out inserting the pulmonary autograft in the aortic position as a total root which was always reconstructed with cryopreserved pulmonary homograft, the mean homograft diameter was 26.1 +/- 4 mm (19-35).

RESULTS

In all patients a transesophageal echocardiogram was performed in the operating room and postoperative, 1 or 2 months later. Only in one patient a mild aortic regurgitation was detected, no significant transaortic or transpulmonary gradients were detected postoperative. One patient was reoperated for bleeding in the postoperative course, there was no hospital mortality in our group and all the patients had an uneventful postoperative period. In the short term follow-up (41-155 days). All the patients are free of anticoagulant therapy, all them are in New York Heart Association Functional Class I.

CONCLUSIONS

The patients presented in this publication which include adult and pediatric, are the first group of patients operated in our country with some excellent preliminary results. We hope that this procedure will become popular and that other surgical groups will adopt it as another surgical tool to replace a diseased aortic valve.

The Spanish Monostrut Study Group: a ten-year experience with 8,599 implants

BACKGROUND

The Monostrut valve is a pyrolytic carbon, tilting-disc prosthesis with no welds. After the first implantation in Spain in May 1983, the Spanish Monostrut Study Group was established to evaluate prospectively the performance of the valve using uniform protocols.

METHODS

During a 10-year period, 8,599 Monostrut valves were implanted in 7,317 patients in 22 centers. Mean age was 53.3 +/- 11 years. Of the total group, 3,229 underwent aortic valve replacement, 2,806 had mitral valve replacement, and 1,282 had double valve replacement. Follow-up was 96% complete, with a mean period of 4.3 years and a total of 29,155 patient-years.

RESULTS

The operative mortality rate was 7.2%. The 10-year probability of freedom from valve-related complications and linearized rates (event/100 patient-years in parentheses) were as follows: structural deterioration, 100% (0); nonstructural dysfunction, 96% +/- 0.5% (0.51); thromboembolism, 82.9% +/- 1.5% (1.32); anticoagulant-related hemorrhage, 87.6% +/- 1.4% (0.98); and prosthetic valve endocarditis, 96.1% +/- 0.5% (0.48). There were five obstructive valve thromboses (0.017/100 patient-years). Actuarial freedom from reoperation was 95% +/- 0.5% at 10 years. Actuarial freedom from all valve-related morbidity was 70.2% +/- 1.6%; freedom from all valve-related morbidity and mortality (including operative and sudden deaths) was 62.6% +/- 2% (70.1% +/- 2% for aortic valve replacement, 56.9% +/- 2% for mitral valve replacement, and 59.8% +/- 3% for double valve replacement; p < 0.0001). Clinically, 5,988 patients (94%) are in New York Heart Association class I-II.

CONCLUSIONS

The Monostrut valve has shown no structural failures and a low rate of valve-related complications over a 10-year period in a large patient population.

[Value of a short (7 days) prophylactic course of ganciclovir in the prevention of cytomegalovirus disease after heart transplantation]

BACKGROUND

The incidence of cytomegalovirus disease remains important after heart transplantation, mainly in the first months after transplantation. We undertook a study to evaluate a short (7 days) prophylactic administration of ganciclovir to prevent cytomegalovirus disease after heart transplantation.

PATIENTS AND METHODS

There were two groups of patients: patients transplanted in 1993 (37) and patients transplanted in 1992 (38). In the first group, ganciclovir was given intravenously at a dose of 10 mg per kilogram of body weight every day from postoperative day 1 through day 7. In the second group, ganciclovir was not given. Similar regimens of immunosuppression (ATG, deflazacort, azathioprine and cyclosporine) were given.

RESULTS

Age, sex, serology in recipients and donors and incidence of acute rejection were comparable between both groups. Mortality was slightly higher in ganciclovir group (35%) than in control group (26%), although this difference was not statistically significant. There were two cases of cytomegalovirus disease in the ganciclovir group (6%) and nine cases in the control group (27%) (p < 0.05), all of them treated successfully. Cytomegalovirus disease in ganciclovir group occurred in two children, who were seronegative before transplantation. The incidence of cytomegalovirus disease in the pediatric recipients of ganciclovir group were 50% (2 of 4) and 100% in the control group (1 of 1). The incidence of cytomegalovirus disease were therefore 0% in the adult subgroup of ganciclovir group and 24% in the adult subgroup of control group.

CONCLUSIONS

A short (7 days) prophylactic administration of ganciclovir reduces the incidence of cytomegalovirus disease. In the pediatric group, the effectiveness is lower.

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.

Comparative evaluation of pentoxifylline, buflomedil, and nifedipine in the treatment of intermittent claudication of the lower limbs

In the light of the current controversy surrounding the use of hemorheologic and vasodilator drugs in the treatment of peripheral arteriosclerosis, a comparative study was designed in order to evaluate the efficacy of pentoxifylline, buflomedil, and nifedipine in 45 patients with peripheral arterial disease (Fontaine stage II). The patients in this prospective randomized study were divided into three groups: 15 patients received pentoxifylline treatment (1,200 mg/day), 15 were treated with buflomedil (600 mg/day), and 15 with nifedipine (60 mg/day). Response to treatment was assessed at the start of the study and after forty-five and ninety days, by clinical examination, Doppler test, strain test, and digital occlusion plethysmography using a strain gauge ring. Pentoxifylline was significantly more effective (P < 0.05) than buflomedil and nifedipine at ninety days in improving walking performance, resting toe pressure, resting and postexercise ankle/brachial pressure ratio, and basal/postischemic toe-pulse ratio. Significant differences within groups were also noted for initial claudication, toe peak-flow time, pulse reappearance time (PRT/2), and maximum postischemic flow time, together with significant intergroup variables. In conclusion, pentoxifylline proved more effective than the other drugs tested in: 1. improving distal pressure and resting microcirculatory blood flow; 2. increasing postexercise distal flow, ratios, and pressures and enabling faster recuperation of basal pulse rates; 3. increasing initial claudication distance in the strain test within the test group and achieving a greater absolute subjective claudication distance than that obtained using the other treatments.

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)

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)

Early open mitral commissurotomy: long-term results

It has frequently been suggested that early mitral commissurotomy could improve long-term results in patients with severe mitral stenosis. However, the real advantages of this procedure have yet to be demonstrated. To evaluate this hypothesis, we retrospectively studied 397 patients who underwent operation for mitral stenosis in our unit between 1978 and 1988. Forty of these patients (group I) fulfilled the criteria for early mitral commissurotomy: being young (average age 33 years), being asymptomatic or showing few symptoms, and being in sinus rhythm. The remaining 357 patients who underwent operation during the same period of time served as control (group II). Mitral valve replacement (p < 0.05) and associated tricuspid annuloplasty (p < 0.05) occurred less frequently in patients from group I than it did in patients from group II. Survival after 11 years for patients with early mitral commissurotomy was 100%, 90% of whom were in functional class I, were in sinus rhythm, and were receiving no medication whatsoever. Ninety-six percent of these patients were free of complications after 11 years, compared with 73% of patients in group II (p < 0.05). In our opinion, these results support the use of early mitral commissurotomy for young patients in sinus rhythm, who are symptom free, who are and who have a mitral valve area is 1.3 cm2 or less.

Preliminary experience with deflazacort, a new synthetic steroid with fewer undesirable side effects, in heart transplant patients

Prednisone is widely used by most heart transplant units, despite its frequent side effects. Deflazacort, a new oral synthetic steroid with fewer side effects, has not been studied in heart transplant patients. Our initial experience with 26 heart transplant patients in whom prednisone was replaced by deflazacort at 11 +/- 11 months after transplantation is reported. After the switch to deflazacort, a significant decreased was noted in glycemia, total cholesterol, and LDL-cholesterol (p < 0.001). No difference was noted in severity or frequency of rejection and infection between patients being treated with deflazacort and another 26 patients who continued to be treated with prednisone over a comparable period of time after transplantation.

[Orthotopic heart transplant. Study of early morbimortality (< or = 30 days). Experience at the Reina Sofía Hospital (Córdoba)]

From may 1986 to december 1991, we have performed 90 heart transplantation in the Hospital "Reina Sofía" from Córdoba. In the present study we analyze the early morbidity and mortality in a retrospective study on complications and factors determining its incidence. Seventy patients were male (86%) and 13 female (14%). Age ranged from 12 and 65 years. The 31% of patients needed in pharmacological support before transplantation, 15 of them were operated in a emergency situation because of cardiogenic shock. The pulmonary resistances oscillated between 0.5 and 8.7 units/m2 (Wood) (mean 2.5 +/- 1.4 units/m2). The mean time of ischaemia was 136 +/- 38 minutes (range 5-255 min). Hospital mortality (< or = 30 days) was 8.8% (8/90). No predictive factors from donor and recipient were found. Three main influences on complications were analyzed: a) influence of myocardial temperature, b) role of hematic cardioplegia, and c) usefulness of Aprotinin. Eighteen patients (20%) developed severe bradyarrhythmia needing a pacemaker in the post-operative period. We found a significant relationship with myocardial temperature (4.3 +/- 2.1 vs 6.2 +/- 2.6; p < 0.05) and transport solution temperature (5.8 +/- 2.3 vs 7.3 +/- 1.9; p < 0.05). No significant influence was found on the time of ischaemia, previous heart disease, previous treatment with Amiodarona, clinical condition, etc.(ABSTRACT TRUNCATED AT 250 WORDS)

Intra- and postoperative fibrinolysis in patients undergoing cardiopulmonary bypass surgery

The influence of cardiopulmonary bypass (CPB) on fibrinolytic activity was assessed in 100 patients with valvular heart disease or atrial septal defects. Euglobulin fibrinolytic activity (EFA), tissue type plasminogen activator (t-PA) activity, plasminogen activator inhibitor 1 (PAI-1) activity, plasminogen, alpha 2-antiplasmin (alpha 2-AP), fibrinogen degradation products (FDP), and D-dimer were measured pre-, intra-, and postoperatively. There were significant increases in EFA and t-PA activity (p less than 0.002), and decreases in plasminogen and alpha 2-AP (p less than 0.0001) intraoperatively with respect to baseline values. t-PA activity decreased significantly after surgery (p less than 0.002), whereas PAI-1 activity showed a marked increase shortly after operation and on postoperative day 1 (p less than 0.0001). FDP and D-dimer levels were significantly increased both intra- and postoperatively, the latter showing higher values (p less than 0.01 and p less than 0.0001, respectively). This study shows that there is an activation of the fibrinolytic system, as a result of the increased activation of plasminogen and decreased levels of plasmin inhibitors, during CPB surgery followed by a postoperative fibrinolytic shutdown.

[Nutritional and immunologic state of patients undergoing heart valve surgery]

A series of 60 consecutive patients treated by heart valve replacement surgery under extracorporeal circulation were reviewed. Poor nutrition was assessed in 28% of these cases, the cardiac index in these patients being significantly smaller than in operated patients with normal nutritional states (2.07 +/- 0.8 as against 2.46 +/- 0.7, p less than 0.01). Furthermore, 58% of those with poor nutrition presented postoperative complications: mediastinitis, wound infection, ventricular arrhythmias or secondary pulmonary infection. One death occurred in this group. Postoperative complications in patients with normal nutritional states developed in only 6% and there were no deaths. Duration of hospital stay was significantly longer in patients with poor nutrition (p less than 0.05). Apart from immunoglobulin levels, all immunologic parameters underwent postoperative modifications related to nutritional state. Physiopathologic hypotheses are proposed as well as a programme for increasing nutritional intake in patients in a precarious metabolic state which predisposes them to complications.