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Introduction Acute respiratory failure is the leading cause of hospitalization in pediatrics. High-flow nasal cannulas (HFNCs) offer a new alternative, but the evidence and indications are still debated. The performance of HFNCs at high altitude has not been described to date. Objective To describe the use of HFNCs in pediatric patients admitted with respiratory failure and explore the factors associated with treatment failure. Methodology A prospective cohort study was carried out in patients between 1 month and 18 years of age managed with HFNCs. The demographic and treatment response data were recorded at baseline and after 1, 6 and 24 h. The number of failures was determined, as well as the length of stay, complications and mortality. Patients with treatment failure were compared with the rest. Results A total of 539 patients were enrolled. Infants (70.9%) of male sex (58.4%) and airway diseases such as asthma and bronchiolitis (61.2%) were more frequent. There were 53 failures (9.8%), with 21 occurring in the first 24 h. The median length of stay was 4 days (IQR 4); there were 5 deaths (0.9%) and 13 adverse events (epistaxis) (2.2%). Improvement was observed in vital signs and severity over time, with differences in the group that failed, but without interactions. The final logistic model established an independent relationship of failure between the hospital (OR 2.78, 95%CI 1.48–5.21) and the initial respiratory rate (OR 1.56, 95%CI 1.21–2.01). Conclusions HFNCs afford good clinical response, with few complications and a low failure rate. The differences found between institutions suggest a subjective relationship in the decision of therapy failure.

Introducción: El fallo respiratorio agudo es la principal causa de hospitalización en pediatría. Las cánulas nasales de alto flujo (CNAF) ofrecen una nueva alternativa, pero sigue existiendo debate en torno a la evidencia e indicaciones. No se ha descrito su comportamiento en gran altitud. Objetivo: Describir el uso de CNAF en pacientes pediátricos que ingresan con insuficiencia respiratoria y explorar los factores asociados al fracaso de la terapia. Metodología: Estudio de cohortes prospectivo. Pacientes entre un mes y 18 anos ˜ manejados con CNAF. Se describieron datos demográficos y se evaluó la respuesta al inicio, 1.a , 6.a y 24.a horas. Se determinó el número de fracasos, así como estancia, complicaciones y mortalidad. Se compararon los pacientes con fracaso al tratamiento. Resultados: Ingresaron 539 pacientes. Fueron más frecuentes los lactantes (70,9%) de sexo masculino (58,4%) con afecciones respiratorias como asma y bronquiolitis (61,2%). Se presentaron 53 fracasos (9,8%), 21 en las primeras 24 horas. La mediana de estancia fue de 4 días (RIQ 4), hubo 5 éxitus (0,9%) y 13 eventos adversos ---epistaxis--- (2,2%). Se observó mejoría de signos vitales y gravedad en el tiempo con diferencias en el grupo que fracasó, pero sin interacciones. El modelo logístico final estimó una relación independiente del fracaso, entre el hospital (OR 2,78; IC95% 1,48-5,21) y la frecuencia respiratoria inicial (OR 1,56; IC95% 1,21-2,01).Conclusión: La CNAF es un sistema con buena respuesta clínica, pocas complicaciones y una baja tasa de fracasos. Las diferencias entre las instituciones sugieren una relación subjetiva de la decisión del fracaso. Introduction: Acute respiratory failure is the leading cause of hospitalization in pediatrics. High-flow nasal cannulas (HFNCs) offer a new alternative, but the evidence and indications are still debated. The performance of HFNCs at high altitude has not been described to date. Objective: To describe the use of HFNCs in pediatric patients admitted with respiratory failure and explore the factors associated with treatment failure. Methodology: A prospective cohort study was carried out in patients between 1 month and 18 years of age managed with HFNCs. The demographic and treatment response data were recorded at baseline and after 1, 6 and 24 hours. The number of failures was determined, as well as the length of stay, complications and mortality. Patients with treatment failure were compared with the rest. Results: A total of 539 patients were enrolled. Infants (70.9%) of male sex (58.4%) and airway diseases such as asthma and bronchiolitis (61.2%) were more frequent. There were 53 failures (9.8%), with 21 occurring in the first 24 hours. The median length of stay was 4 days (IQR 4); there were 5 deaths (0.9%) and 13 adverse events (epistaxis) (2.2%). Improvement was observed in vital signs and severity over time, with differences in the group that failed, but without interactions. The final logistic model established an independent relationship of failure between the hospital (OR 2.78, 95%CI 1.48-5.21) and the initial respiratory rate (OR 1.56, 95%CI 1.21-2.01). Conclusions: HFNCs afford good clinical response, with few complications and a low failure rate. The differences found between institutions suggest a subjective relationship in the decision of therapy failure.

Acute respiratory failure is the leading cause of hospitalization in pediatrics. High-flow nasal cannulas (HFNCs) offer a new alternative, but the evidence and indications are still debated. The performance of HFNCs at high altitude has not been described to date.To describe the use of HFNCs in pediatric patients admitted with respiratory failure and explore the factors associated with treatment failure.A prospective cohort study was carried out in patients between 1 month and 18 years of age managed with HFNCs. The demographic and treatment response data were recorded at baseline and after 1, 6 and 24hours. The number of failures was determined, as well as the length of stay, complications and mortality. Patients with treatment failure were compared with the rest.A total of 539 patients were enrolled. Infants (70.9%) of male sex (58.4%) and airway diseases such as asthma and bronchiolitis (61.2%) were more frequent. There were 53 failures (9.8%), with 21 occurring in the first 24hours. The median length of stay was 4 days (IQR 4); there were 5 deaths (0.9%) and 13 adverse events (epistaxis) (2.2%). Improvement was observed in vital signs and severity over time, with differences in the group that failed, but without interactions. The final logistic model established an independent relationship of failure between the hospital (OR 2.78, 95%CI 1.48-5.21) and the initial respiratory rate (OR 1.56, 95%CI 1.21-2.01).HFNCs afford good clinical response, with few complications and a low failure rate. The differences found between institutions suggest a subjective relationship in the decision of therapy failure.

Much of the energy available to the earth comes from the sun, it is the largest source of radiation, emitting approximately 1353 W/m2 of energy into the Earth’s atmosphere, in the form of electromagnetic waves, with wavelengths (λ) between 0,3 and 3 μm. Within this spectrum we find the following radiations: Gamma (1%), Ultra violet (4%), Luminous (49%) and Infrared (46%). Only 51% of the solar radiation that enters the atmosphere reaches the earth’s surface. This radiation represents a main source for renewable energy, presenting great applicability in solar thermal energy and specifically in the use of parabolic cylindrical solar collectors; that take advantage of this radiation to raise the temperature of a fluid, located in a receiving tube. The great problem of these systems is to generate a good design, which allows to reach high temperatures and good yields, therefore, many investigations have generated multiple design software, which mitigates the margin of error, but generally this software are limited; With licenses, they are complex and do not specify all the features for processing. The main objective of this research is an open source library that allows obtaining the highest efficiency of parabolic cylindrical collectors, based on the theoretical references Duffie, Beckman and Kalogirou. For this, the Matlab software and the Soltrace tool were taken into account, in order to validate the sizing and optical, thermal, geometric and global performance. Within the results, the maximum concentration ratio of the parabola is checked, which is obtained when the edge angle is 90 °. A functional library can be generated, where multiple measurements and shapes of the parabola were simulated, obtaining the highest overall performance, when the focal length is equal to the maximum height of the parabola, obtaining a performance of 62.64%.

Introducción. Esta investigación observa la identificación de receptores homosexuales y heterosexuales de ambos sexos con las protagonistas lesbianas de ficciones audiovisuales en España. Metodología. El estudio aplica un método mixto, compuesto por dos investigaciones independientes cuyos resultados se interpretan conjuntamente: la cuantitativa determina magnitudes de los efectos y la cualitativa los explica. Resultados. Los resultados muestran que el sexo del receptor no afecta a las magnitudes de la identificación, aunque sí a las razones por las que se produce; que la orientación sexual del receptor, en cambio, sí afecta, y que las reacciones de los hombres heterosexuales son significativamente más indiferentes. Además, revela que el peso en la identificación se halla en la empatía afectiva con los personajes. Discusión y Conclusiones. La aplicación de una metodología mixta aporta profundidad. El uso de escalas de identificación en la recolección de datos del cuantitativo obliga al participante a posicionarse dentro del rango de valores disponibles, pero las entrevistas del método cualitativo, permiten revelar la amplitud de significados vinculados a esos valores. Como se esperaba (H1), el contenido de la ficción afecta a la identificación con los personajes lesbianos. La protagonista moralmente más virtuosa induce a mayor identificación, y ésta se produce, además, por razones más homogéneas entre las poblaciones de distinto sexo u orientación sexual. Asimismo, se encuentran razones para refutar que el sexo del receptor afecta a la identificación con los personajes de lesbianas (H2). También, se confirma que existen diferencias enla identificación en función de la orientación sexual general (H3). Dichas diferencias, sin embargo, no se producen únicamente en las magnitudes generales, sino en las motivaciones para la identificación. La resonancia personal que evocan las historias y la similitud de las historias con experiencias propias, son los dos factores de peso en la identificación de los homosexuales. Además, se encuentra que estas narrativas son procesadas de forma distinta por homosexuales y heterosexuales. Las respuestas de los heterosexuales masculinos son siempre más distantes e indiferentes que las de las heterosexuales femeninas o las de los homosexuales de ambos sexos. Introduction: This research explores the identification of homosexual and heterosexual men and women receivers with lesbian protagonists of audiovisual fictions, in Spain. Methodology: The study uses a mixed method, consisting of two independent investigations whose results are interpreted together: a quantitative investigation determines the magnitudes of the effects, and a qualitative one explains the reasons for them. Results: The results show that the sex of the receivers does not affect the magnitudes of identification, but the reasons for identification. However, results show that the sexual orientation of the receiver does affect identification. Finally, they show that the reactions of heterosexual men are significantly more indifferent to lesbian characters and the stories set in lesbian communities. Furthermore, the investigation finds that the principal weight on identification derives from the affective empathy with characters. Discussion and Conclusions: The application of a mixed methodology provides depth. The use of scales in the identification of quantitative data collection requires the participant to take a position within the range of values ​​available, but interviews of a qualitative method can reveal the extent of meanings attached to these values. As expected (H1), the content of fiction affects lesbian identification characters. The morally virtuous protagonist induces greater identification, and it is produced by similar reasonsamong populations of different sex or sexual orientation. In addition, there are reasons to refute the gender of the receiver's affected identification with lesbian characters (H2). It also confirms that there are differences in the identification based on the general sexual orientation (H3). These differences, however, do not happen only in the general magnitudes, but in the motivations for identification. The personal resonance evoked by stories and the similarity of the stories with their own experiences, are the two important factors for homosexuals' identification. In addition, we find that homosexuals and heterosexuals process these narratives in differently ways. The responses of male heterosexuals are always distant and indifferent to those of heterosexual women or gay men and women.

To evaluate the pattern of brain natriuretic peptide (BNP) concentration in heart transplant (HT) recipients and its relation to the degree of graft rejection determined by endomyocardial biopsy specimen.We studied 71 consecutive HT recipients (62 men, 53 +/- 11 years). The patients underwent 383 biopsies. Creatinine and BNP concentrations and hemodynamic parameters were determined along with the degree of graft rejection using endomyocardial biopsy specimens. We considered treatable rejection as International Society for Heart and Lung Transplantation Gradeor=2 in the first 90 days andor=3A thereafter. We included a control group of 36 healthy individuals.Brain natriuretic peptide concentration was significantly greater among HT recipients (264 +/- 318 pg/ml) than in controls (17 +/- 16 pg/ml). In the first 90 days, BNP concentration was significantly greater among the patients with graft rejection (510 +/- 470, n = 84, vs 278 +/- 255, n = 87; p0.0001), although the corresponding discriminatory capacity was small. After the first 90 days, BNP values were similar in patients with and without graft rejection (170 +/- 297, n = 17, vs 142 +/- 203, n = 195; p = not significant). Creatinine concentration increased with time after transplantation and did not correlate with BNP concentration. We observed significant positive correlation between BNP concentration and hemodynamic parameters.Brain natriuretic peptide concentration remains increased after HT, with stabilization after the 4th month. Brain natriuretic peptide concentrations are slightly greater among patients with treatable rejection, particularly in the first 90 days, although BNP concentration lacks discriminatory capacity to serve as a guide to performing biopsy.

Burkholderia pseudomallei, a gram-negative bacterium, is the causative agent of melioidosis in humans and animals (9, 13, 45). Melioidosis is endemic in tropical areas of Southeast Asia and northern Australia, but it is also sporadically found in many other countries. This highly pathogenic microorganism is deemed a potential agent of bioterrorism (listed as category B by the Centers for Disease Control and Prevention). The clinical manifestations of melioidosis vary greatly, ranging from an asymptomatic state to acute septicemia, pulmonary forms, and chronic granulomatous lesions (34). The latency period of the disease is between 2 days and 26 years (21, 34). Successful treatment is difficult because B. pseudomallei is inherently resistant to a wide range of antibiotics and relapse is common (43). Although melioidosis was first described in 1912 (44), the virulence determinants of B. pseudomallei have not been well characterized. Studies of B. pseudomallei pathogenicity have mostly concentrated on exoproducts, which include a protease, a lipase, a phospholipase C, and a hemolysin (3, 34, 45). The regulatory circuits governing the production of exoproducts in B. pseudomallei remain unknown. However, many gram-negative pathogens regulate the production of extracellular virulence factors by quorum sensing, a cell-density-dependent mechanism. Quorum sensing is the process of producing and responding to high intracellular concentrations of N-acylhomoserine lactone (AHL) autoinducers and relies on two proteins: (i) an AHL synthase belonging to the LuxI family, which directs the synthesis of AHL; and (ii) a transcriptional regulator belonging to the LuxR family, which, after binding of AHL, is thought to activate or repress transcription of targeted genes (11, 22, 29). In Burkholderia cepacia, which is phylogenetically related to B. pseudomallei (13), the CepI-CepR quorum-sensing system positively regulates protease production and represses synthesis of the siderophore ornibactin (19). There has been much interest in the contribution of the B. pseudomallei protease to virulence. This enzyme was purified from culture supernatants as a 36-kDa metalloenzyme and appeared to be necessary for full virulence in a rat model of lung infection (32). In contrast, we found no correlation between virulence and the level of protease activity after intraperitoneal infection of mice with B. pseudomallei (12). These results suggested that the role played by the protease in pathogenesis could be dependent on the route of infection. Recently, the mprA gene of B. pseudomallei was cloned and was found to encode a 50-kDa serine metalloprotease, the only protease produced by B. pseudomallei (17). However, the discrepancy with the size determined by Sexton et al. (32) has not been explained yet; perhaps the difference is due to proteolysis or the use of different techniques (17). Our previous investigations on the B. pseudomallei protease (12, 25) led us to examine whether enzyme production is regulated by quorum sensing. The role of quorum-sensing systems in the pathogenicity of different gram-negative bacteria has been demonstrated previously (28, 35). The existence of such a system in B. pseudomallei could provide new data on the virulence determinants of this organism. Here we describe identification of the PmlI-PmlR quorum-sensing system of B. pseudomallei. This system is crucial for full virulence of B. pseudomallei in a murine model of infection and modulates the production of the MprA protease.

Introduction and objective. Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF. Material and method. In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model. Results. The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01). Conclusions. AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

Introduccion y objetivos En la actualidad se han identificado diversos marcadores bioquimicos en la insuficiencia cardiaca (IC) que podrian indicarnos la gravedad del paciente. De entre ellos, el probablemente mas util por la facilidad de su obtencion e informacion diagnostica-pronostica es el peptido cerebral natriuretico (BNP). Nuestro objetivo fue analizar la asociacion entre el BNP y diferentes variables asociadas a la IC, asi como calcular su poder discriminante del tipo de IC (sistolica frente a diastolica). Pacientes y metodo Estudiamos a 114 pacientes ingresados de forma consecutiva por IC descompensada, cualquiera que fuera su etiologia (edad media: 66 anos, varones: 60%). En todos ellos se determino la concentracion de BNP, en muestras sanguineas obtenidas a partir del tercer dia de ingreso hospitalario, mediante ensayo radioinmunometrico. En 101 pacientes se realizo estudio ecocardiografico. Resultados Las concentraciones plasmaticas de BNP fueron mayores en pacientes con grados avanzados de estadio funcional (p = 0,01), sexo masculino (p = 0,008), mayor creatinina plasmatica (p = 0,01, r = 0,25), peor funcion sistolica del ventriculo izquierdo (p = 0,0001, r = 0,44), mayores diametros ventriculares (p = 0,0001) y mayor presion sistolica de la arteria pulmonar (p = 0,001, r = 0,44). En el analisis multivariado, el BNP se asocio de forma independiente del resto de variables con la funcion sistolica del ventriculo izquierdo (p = 0,0001). A pesar de esta asociacion, ningun valor de BNP fue capaz de discriminar con un adecuado valor de sensibilidad y especificidad, del total de pacientes con IC, cuales presentaban disfuncion sistolica. Conclusiones a) El BNP aumenta de forma proporcional a la disfuncion ventricular izquierda y la gravedad de la insuficiencia cardiaca, y b) el BNP no puede emplearse en el diagnostico diferencial del tipo de IC (disfuncion sistolica frente a diastolica).

Introduccion y objetivos En el infarto agudo de miocardio (IAM) anterior, el lugar de la oclusion de la arteria descendente anterior (DA) se relaciona con la extension de la necrosis y con el pronostico. El proposito del estudio fue valorar la utilidad del electrocardiograma (ECG) para predecir el lugar de la oclusion de la DA en pacientes con IAM anterior y enfermedad aislada de la DA. Metodos Estudio retrospectivo en el que se incluyen a 45 pacientes consecutivos con un primer IAM de localizacion anterior y enfermedad aislada de la DA. Analizamos el ECG que mostro la mayor desviacion del segmento ST (ST) previo al tratamiento fibrinolitico y lo correlacionamos con el nivel lesional en la DA en coronariografia realizada antes del alta hospitalaria en relacion con la primera septal dominante y primera diagonal, distinguiendo: territorio septal afectado («S»), territorio diagonal afectado («D»), ambos afectados («S + D») o ninguno. Resultados El descenso del segmento ST en las derivaciones II, III o aVF fue un potente predictor de lesion proximal en la DA en las localizaciones angiograficas «S + D», «S» y «D» (p = 0,003, p = 0,04 y p = 0,02, respectivamente). El ascenso del ST en II, III o aVF unicamente se observo en pacientes con una DA desarrollada que daba la vuelta al apex y se relaciono con lesion distal a la diagonal dominante (p Conclusiones En el IAM anterior y enfermedad exclusiva de la DA, el ECG puede ser una herramienta util en la prediccion del nivel lesional de la DA en relacion con sus ramas principales.

El sindrome de robo subclavio-coronario es una rara causa de isquemia miocardica recurrente en pacientes intervenidos de bypass aortocoronario con injerto de arteria mamaria interna izquierda. Una estenosis significativa en la arteria subclavia izquierda proximal a su origen puede originar un flujo reverso en dicho injerto e isquemia miocardica. Describimos el caso de una paciente de 76 anos, intervenida de cirugia coronaria 7 meses antes, con clinica de angina refractaria y isquemia electrocardiografica en el territorio de la arteria descendente anterior. La arteriografia confirmo este sindrome y la paciente fue tratada de forma exitosa mediante angioplastia percutanea y colocacion de 2 stents en la arteria subclavia izquierda. Revisamos el manejo clinico, asi como el diagnostico y las opciones terapeuticas en el sindrome de robo subclaviocoronario.

Introduccion y objetivos Poseemos insuficiente informacion sobre como se trata a los pacientes con infarto agudo de miocardio en Espana. Con el fin de subsanar esta deficiencia, la Seccion de Cardiopatia Isquemica y Unidades Coronarias de la Sociedad Espanola de Cardiologia inicio a finales de 1994 un registro de pacientes con infarto atendidos en las unidades coronarias de los hospitales espanoles, que se mantiene abierto en la actualidad. Metodos El reclutamiento de pacientes se realiza en hospitales con unidad coronaria. Se recogen caracteristicas demograficas, factores de riesgo y antecedentes de enfermedad coronaria asi como complicaciones clinicas y procedimientos diagnosticos y terapeuticos utilizados durante la estancia en la unidad coronaria. Resultados Durante el periodo 1995-1999 se registraron un total de 28.537 pacientes. La edad media aumento ligeramente (de 64,4 ± 12,2 a 65,2 ± 12,7 anos; p Conclusiones En nuestro medio, en el periodo 1995-1999, aumento el porcentaje de pacientes que reciben aspirina, bloqueadores beta e inhibidores de la enzima convertidora de la angiotensina en la fase aguda del infarto. Sin embargo, se estabilizo la utilizacion de tromboliticos y el retraso en su administracion. Disminuyo la estancia media en la unidad coronaria asi como la mortalidad precoz, a pesar de que las caracteristicas clinicas de los pacientes no mejoraron.

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

Percutaneous mitral valvuloplasty has become the technique of choice for mitral stenosis with favorable anatomic features. However, mitral regurgitation is an important complication of this technique that has not reduced with Inoue technique. This study reports the clinical and echocardiographic follow-up (28 +/- 20 months) of 20 patients who developed severe mitral regurgitation after percutaneous mitral valvuloplasty with Inoue technique. The patients were divided into two groups on the basis of the need for mitral valve replacement during follow-up. We analyzed variables before and after percutaneous mitral valvuloplasty using univariate analysis. Multivariate analysis was performed to identify variables as independent predictors of the need for mitral valve replacement. Ten patients needed mitral valve replacement during follow-up. Multivariate analysis showed that suboptimal result of percutaneous mitral valvuloplasty (MVA < 1.5 cm2) was the only independent predictor of the need of mitral valve replacement. We concluded that the need for MVR in patients who develop severe mitral regurgitation after percutaneous mitral valvuloplasty was related to suboptimal result of procedure.

El corazon univentricular es una cardiopatia congenita poco frecuente. Un grupo seleccionado de estos pacientes (aquellos que ademas presentan una estenosis o atresia pulmonar) puede llegar a la edad adulta con mayor o menor incidencia de insuficiencia cardiaca o hipoxemia cronica severa. Los pacientes con un desarrollo adecuado del arbol pulmonar pueden ser subsidiarios de un trasplante cardiaco, en caso de estar contraindicadas las tecnicas habituales de paliacion. Presentamos tres casos de corazon univentricular y estenosis pulmonar en los que se indico un trasplante cardiaco como mejor opcion. Asi mismo, analizamos las distintas tecnicas disponibles para la valoracion del desarrollo del arbol pulmonar y su utilidad.

Objetivo Valorar la eficacia a largo plazo de la valvuloplastia mitral percutanea en nuestro centro, asi como evaluar la existencia de predictores de supervivencia libre de eventos cardiovasculares a largo plazo. Pacientes y metodos Entre 1990 y 1996 se han realizado 204 valvuloplastias mitrales con cateter balon de Inoue. La poblacion de estudio esta constituida por 132 pacientes con un seguimiento superior a 9 meses. El seguimiento medio fue de 2,6-1,5 anos (7 dias-5,7 anos). Los objetivos finales de este estudio fueron la necesidad de cirugia mitral, la muerte y la situacion funcional III-IV durante el seguimiento. Se realizo un analisis de la supervivencia determinando la existencia de factores predictores independientes de la supervivencia libre de eventos. Resultados Al finalizar el seguimiento un 88% de los pacientes se encontraban en clase funcional I-II de la New York Heart Association y libres de eventos. El analisis multivariado determino como factores predictores independientes de la aparicion de eventos cardiovasculares a largo plazo la mayor rigidez y engrosamiento valvular, la existencia de una auricula izquierda severamente dilatada, como factores previos a la valvuloplastia mitral percutanea y la obtencion de un resultado suboptimo y la insuficiencia mitral significativa tras la valvuloplastia mitral percutanea. Conclusiones La valvuloplastia mitral percutanea con cateter balon de Inoue es una tecnica segura y eficaz, cuya eficacia se mantiene a largo plazo; los mejores resultados a largo plazo se obtienen en pacientes con valvulas flexibles y poco engrosadas, con auricula izquierda leve o moderadamente aumentada y en aquellos en los que el resultado se considera optimo y no presentan una insuficiencia mitral severa como complicacion del procedimiento.

Objetivo El proposito de este estudio fue analizarvariables del donante, receptor y quirurgicaspara descubrir factores que pudieran predecir mortalidaddurante la fase precoz ( Material y metodo Se analizaron 125 trasplantescardiacos ortotopicos consecutivos de adultos. Laedad media fue de 51 ± 11 anos (rango, 12-67), 109fueron varones (87%) y 16 mujeres (13%). Se compararondos grupos segun los pacientes hubieranfallecido o no durante los primeros 30 dias tras eltrasplante cardiaco (15 y 110 pacientes, respectivamente). Protocolo inmunosupresor: en el preoperatorio,ciclosporina mas azatioprina. En el intraoperatorio,metilprednisolona. En el postoperatorio, metilprednisolona(primeras 24 h), anticuerpos monoclonalesantilinfociticos (7-10 dias posterioresal trasplante), ciclosporina, azatioprina y corticoides. Se analizaron los siguientes parametros del receptor:sexo, edad, peso, talla, perimetro toracico,cardiopatia de base, intervenciones toracicas previas,estadio funcional o necesidad de catecolaminaslos dias previos al trasplante, presiones y resistenciaspulmonares, historia de hipertensionarterial sistemica, elevacion de creatinina, gruposanguineo, trasplante realizado de forma urgente yrelacion de peso receptor/donante. Se analizaronlos siguientes parametros del donante y la intervencion:sexo, edad, peso, perimetro toracico, diasde estancia en cuidados criticos, dosis de dopaminay dobutamina, grupo sanguineo, procedencia delorgano, causa de muerte, tiempo de isquemia y circulacionextracorporea y tipo de cardioplejia. Resultados La tasa de mortalidad precoz ennuestra serie fue del 12%. En el analisis univariantese observaron diferencias en cuanto a los antecedentesde cirugia cardiovascular, grupo sanguineodel receptor, necesidad de realizar eltrasplante de una forma urgente, resistencias vascularespulmonares superiores a 2,5 UW, tiempo decirculacion extracorporea y la relacion de pesosentre el receptor y el donante. Se aproximo a lasignificacion la causa de muerte del donante. Elanalisis multivariante senalo, como parametros convalor predictivo independiente de mortalidad precoz,los antecedentes de intervencion con circulacionextracorporea, las resistencias vascularespulmonares elevadas, el trasplante urgente, la relacionde pesos receptor/donante y el tiempo de circulacionextracorporea. Conclusiones Pensamos que los resultados denuestra experiencia pueden ayudar a estratificar elriesgo ante un receptor de trasplante cardiaco ortotopico,e incluso contraindicar el procedimientoen determinados casos con acumulacion de factoresde mal pronostico en receptores «limite».

Background Certain cardiovascular risk factors have been linked to morbidity and mortality in heart transplant (HT) patients. The sum of various risk factors may have a large cumulative negative effect, leading to a substantially worse prognosis and the need to consider whether HT is contraindicated. The objective of this study was to determine whether the risk factors usually available prior to HT result in an excess mortality in our setting that contraindicates transplantation. Materials and methods Consecutive patients who underwent heart transplantation from November 1987 to January 2004 were included. Heart–lung transplants, retransplants, and pediatric transplants were excluded. Of the 384 patients, 89% were men. Mean age was 52 years (range, 12 to 67). Underlying disease included ischemic heart disease (52%), idiopathic dilated cardiomyopathy (36%), valvular disease (8%), and other (4%). Variables considered risk factors were obesity (BMI >25), dyslipidemia, hypertension, prior thoracic surgery, diabetes, and history of ischemic heart disease. Survival curves by number of risk factors using Kaplan-Meier and log-rank for comparison of curves. Results Overall patient survival at 1, 5, 10, and 13 years was 76%, 68%, 54%, and 47%, respectively. Survival at 10 years, if fewer than two risk factors were present, was 69%; 59% if two or three factors were present; and 37% if more than three associated risk factors were present ( P = .04). Conclusions The presence of certain risk factors in patients undergoing HT resulted in lower survival rates. The combination of various risk factors clearly worsened outcomes. However, we do not believe this should be an absolute contraindication for transplantation.

Los pacientes sometidos a trasplante cardiaco tienen un mayor riesgo de dislipidemia (60%-80%). Debido al conocido papel de la dislipidemia en el desarrollo de enfermedad vascular del injerto, el tratamiento hipolipidemiante deberia ser especialmente agresivo en estos pacientes. El objetivo de este estudio ha sido evaluar la eficacia y seguridad del tratamiento con pravastatina y su efecto sobre los niveles de ciclosporina sobre una poblacion de pacientes trasplantados dislipidemicos. Incluimos, en este estudio prospectivo observacional de 39 semanas de duracion, a 20 pacientes trasplantados cardiacos con cifras de colesterol basales por encima de 200 mg/dl, que recibieron tratamiento con pravastatina a la dosis necesaria para alcanzar un optimo perfil lipidico o aparicion de efectos adversos significativos. Pravastatina, a una dosis media de 50 ± 18 mg/dia, produjo una reduccion significativa de los niveles de colesterol (de 291 ± 32 a 203 ± 25 mg/dl, p Observamos un ligero incremento de las cifras de creatinfosfocinasa (CPK) asintomatico y sin mayor relevancia clinica, y los niveles de ciclosporina no experimentaron diferencias significativas. La pravastatina se ha mostrado en nuestro estudio como un tratamiento seguro y eficaz en pacientes trasplantados cardiacos con dislipidemia.

Predicting technical difficulties in performing an epidural block can affect the anesthesiologist's choice of technique or decisions about who should carry it out. Our aim was to determine patient characteristics associated with difficulty in performing an epidural block for obstetric analgesia.We designed a prospective observational study in 540 pregnant women who requested epidural analgesia for obstetric labor. Patient characteristics (age, weight, height), anatomical features (body constitution, visible and/or palpable spinal apophyses, structural anomalies), technical features (number of attempts, repositioning of the needle), anesthesiologist's experience (resident or staff), block success, time taken to accomplish the procedure, and obstetrical variables (parity, gestational age, cervical dilatation).The factor that best correlates with puncture difficulty in the obstetric patient is the presence of visible or palpable spinal apophyses and palpation prior to carrying out the block. Factors like weight, body constitution, or anesthesiologist's experience seem to influence the rate of success or failure of the epidural block for obstetric analgesia, although to a lesser degree.The most important factor for predicting success of an epidural block for obstetric analgesia in our practice is the presence of palpable spinal apophyses.

Introduction It is known that there is a high incidence of diabetes mellitus (DM) among heart transplant (HT) patients, which may be up to 30% at 5 years. The presence of DM has been associated with increased morbidity (infections, renal dysfunction, or graft vascular disease), and its development has been related primarily to immunosuppressive therapy. The objective of this study was to determine, in our experience, the presence of predictive variables for the development of DM following HT. Methods We studied 315 consecutive non-DM patients (88.6% men, mean age 51.5 years) who underwent HT in our hospital from November 1987 to May 2003, analyzing all variables that could be related to the development of DM during follow-up. Student t -test and χ 2 test were used for univariate statistical analysis and logistic regression for multivariate analysis. Results Of the 315 patients, 64 developed DM (20.3%) during a mean follow-up of 3.3 years. The univariate analysis showed that patients developing DM are older (54.9 ± 8.7 versus 50.7 ± 11.8 years, P = .008), have a higher body mass index (BMI) (27.3 ± 3.8 versus 25.7 ± 3.7, P = .003), a higher prevalence of HT (37.5% versus 23.5%, P = .023), a lower frequency of urgent HT (9.4% versus 26.2%, P = .004), are more often treated with steroids (85.9% versus 70.1%, P = .011) and tacrolimus (12.5% versus 4.4%, P = .015), and have a higher frequency of rejection episodes (71.2% versus 44.6%, P = .001). Multivariate analysis identified the following as predictive factors for the development of DM: age (OR = 1.04, P = .013), urgent HT (OR = 0.36, P = .031), treatment with tacrolimus (OR = 3.89, P = .012), and number of rejections (OR = 2.34, P = .002). Conclusion In our population, age, urgent HT (which had a protective effect), treatment with tacrolimus, and number of rejections were independent predictive variables for the development of DM during follow-up.

Epsilon wave is an unusual electrocardiographical finding, which may appear in other pathological conditions besides the arrhythmogenic right ventricular dysplasia, particularly in the acute myocardial infarction of the right ventricle, the inferior, or the posterior wall of the left ventricle. Its real incidence in these acute coronary syndromes remains unknown and will be probably difficult to assert, since it may be unnoticed by inexperienced physicians because of its little voltage. The outstanding interest of this case lies in the clear electrocardiographical images and in the step-by-step differential diagnosis discussed by the authors.

The aim of this study was to determine whether elevated brain natriuretic peptide (BNP) levels after heart transplantation are correlated with the severity of rejection by using endomyocardial biopsy (EMB) and echocardiographic parameters indicative of ventricular function of the transplanted heart. This was an observational study of 80 orthotopic heart transplant recipients (11 women and 69 men; mean age 53+/-11 years). BNP determinations were performed within 48 h of endomyocardial biopsy. The echocardiographic study and BNP determination were also performed in a group of healthy volunteers. We found significantly higher BNP mean levels in heart transplant patients than in healthy volunteers (volunteers, 16.7+/-16.2 pg.ml-1; transplant, 213.4+/-268.6 pg.ml-1; P

Objectives To assess the value of the use of cardiac MRI to detect rejection (necrosis) and its ability to discriminate it from other pathologic alterations (edema and fibrosis). Materials and methods A prospective and consecutive study was designed in which cardiac MRI was performed at the same time as the scheduled endomyocardial biopsy. The study period was from 31-10-01 to 01-05-02. Ten patients with claustrophobia were excluded. Sixty-four examinations were performed in the remaining 40 patients. MRI assessment was blinded to the biopsy result. The 17 biopsies performed were insufficient (too small sample). Rejection was defined as the presence of at least 1 focus of myocyte necrosis. Technique. A high-field (1.5 T) GE CV/i magnetic resonance imaging system was used to obtain pre- and postcontrast white and black blood anatomic sequences (breathhold fast spin-echo T1-weighted images), as well as myocardial cine, perfusion and viability sequences. Variables analyzed. Ejection fraction, ventricular volumes, pericardial effusion, hypertrophy, absolute and relative myocardial intensity and uptake. Statistics. Variables were normally distributed. Student's t test was used for quantitative variables and the χ2 test for proportions. Results Mean age, 51 ± 13 years. Women 5, men 35. Time since HT, 13 to 3725 days. No significant differences were found between rejection and ventricular volumes or the presence of effusion and hypertrophy. Visual estimation of myocardial perfusion and viability sequences did not detect any significant changes. Uptake showed a clear trend to increase in patients with necrosis: 34 ± 21 versus 23 ± 17 for relative uptake, P < .05. There were also differences in uptake when fibrosis was present: 68 ± 47 versus 102 ± 48 in the group without fibrosis, P < .05; but not in the presence of edema: 93 ± 55 versus 94 ± 45 for absolute uptake. Conclusions (1) Cardiac MRI is a promising technique for diagnosis of rejection. (2) Patients with myocyte necrosis show a clear trend toward increased myocardial uptake. (3) Interstitial fibrosis is associated with decreased levels of uptake.

Patients undergoing cardiac transplantation are at increased risk of dyslipidemia (60% to 80%). Lipid-lowering treatment in these patients should be aggressive given the known role of dyslipidemia in chronic transplant rejection. The objective of this study was to evaluate the efficacy and safety of pravastatina therapy and its effect upon cyclosporine levels in a population of dyslipidemic cardiac transplant patients.A total of 20 cardiac transplant patients were enrolled in this 39-week length prospective observational study. Patients had serum cholesterol levels exceeding 200 mg/dl, and received pravastatin therapy at the adequate dose to obtain an optimal lipid profile without significant adverse effects. Pravastatin, at a mean dose of 50 18 mg/day, produced a significant reduction in total cholesterol levels (from 291 32 to 203 25 mg/dl, p0.05), LDL cholesterol (from 187 34 to 102 15 mg/dl, p0.05) and an increase in HDL-cholesterol levels (from 48 16 to 55 14, p0.05). A slight asymptomatic increase in CPK levels was observed but no differences in cyclosporine levels. Pravastatin has shown to be an effective and safe therapy in dyslipidemic cardiac transplant patients.

The coronary-subclavian steal syndrome is a rare cause of recurrent myocardial ischemia in patients who have undergone left internal mammary-coronary artery bypass grafting. A significant left subclavian artery stenosis proximal to its origin, can result in an impaired or reversed flow in this graft and myocardial ischemia. We describe the case of a woman aged 76 who had undergone myocardial revascularization seven months before, and presented refractory angina with severe electrocardiographic ischemia in the left anterior descending artery territory. Arteriography confirmed this syndrome and the patient was successfully treated with percutaneous transluminal angioplasty and placement of two stents in the left subclavian artery. We review the clinical management, diagnostic methods and therapeutic options used in the subclavian-coronary steal syndrome.

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

Background: Currently studies conflict on the impact on mortality of right bundle branch block development after transplantation. Most studies conclude that right bundle branch block does not affect patient survival. However, no distinction is made between patients in whom right bundle branch block progresses and those in whom it remains unchanged during follow-up. The objective of this study is to assess clinical or survival differences between patients who develop right bundle branch block and those who do not, and also to analyze these differences depending on progression of this conduction abnormality. Materials and methods Ninety-seven consecutive heart transplant recipients with more than 1 year’s survival were analyzed. Twelve-lead standard ECGs were performed during the first week after transplantation, which allowed for classification of patients depending on the presence or absence of right bundle branch block. Subsequently, throughout the first year, 2 groups were identified, depending on increase of the conduction defect. The groups were compared and factors determining the presence of right bundle branch block and progression of the conduction defect were found. Survival curves for the conduction defect were also compared. Results Fifty percent of the patients developed right bundle branch block after transplantation; it was progressive in 10. Progressive right bundle branch block was related to greater renal dysfunction (odds ration [OR] = 10.8; confidence interval [CI] = 2–58; p = 0.006), a larger number of rejections ( p = 0.01), and a greater death rate (OR = 12.8; CI = 2.5–64; p = 0.002). The presence of progressive right bundle branch block was an independent predictor of long-term mortality (OR = 27.9; CI = 4.2–186.3; p = 0.0006). Conclusions The development of right bundle branch block after transplantation is related to intraoperative factors and to a greater number of rejections. The presence of this conduction disorder, particularly if it progresses during the first year, identifies a sub-group of patients with a poorer long-term prognosis.

To ascertain whether a given level of antimyosin monoclonal antibody (AMA) uptake in the endomyocardial biopsy (EMB) can identify patients with rejection.186 examinations were performed on 65 patients (8 women and 57 men) with orthotopic heat transplant (HT): Mean age 51 +/- 13 years. There were 3 examinations per patient (range 1-6). The studies were conducted 13 to 880 days after the HT. The C/p uptake indexes were obtained according to the Carrió y cols. method and the results were compared with the biopsy findings. Rejection was considered to be when the biopsy showed at least one site of necrosis.1) We analyzed the C/P index in accordance with the post-HT interval and with the degree of rejection obtained by EMB. No group showed any significant differences between the patients with an without rejection (p0,05). 2) We applied a variable threshold based on post-HT interval, using an exponential curve defined on the basis of the interval of the values corresponding to patients without rejection and good progress compared with that of the rejection patients. This approach also did not contribute any improvement compared to the use of a fixed threshold due to the significant overlay of the values for patients with and without rejection. 3) Finally, we analyzed the individual evolution of the C/P indexes for each patient in terms of time. In patients whose clinical progress was good, the C/P indexes were observed to drop progressively over time. In those whose clinical progress was poor, abrupt increases in the index values were observed.We were unable to differentiate significantly between patients with and without rejection in EMB using fixed and variable thresholds of the C/P index. However, the different patterns of evolution for each patient provide information on the lack of complications and could be used as a follow-up technique.

Percutaneous mitral valvuloplasty has become the technique of choice for mitral stenosis with favorable anatomic features. However, mitral regurgitation is an important complication of this technique that has not reduced with Inoue technique. This study reports the clinical and echocardiographic follow-up (28 +/- 20 months) of 20 patients who developed severe mitral regurgitation after percutaneous mitral valvuloplasty with Inoue technique. The patients were divided into two groups on the basis of the need for mitral valve replacement during follow-up. We analyzed variables before and after percutaneous mitral valvuloplasty using univariate analysis. Multivariate analysis was performed to identify variables as independent predictors of the need for mitral valve replacement. Ten patients needed mitral valve replacement during follow-up. Multivariate analysis showed that suboptimal result of percutaneous mitral valvuloplasty (MVA1.5 cm2) was the only independent predictor of the need of mitral valve replacement. We concluded that the need for MVR in patients who develop severe mitral regurgitation after percutaneous mitral valvuloplasty was related to suboptimal result of procedure.

The study was performed to test the influence of the jet spatial disposition on the correlation degree between the measurement of the jet width at its origin and the severity of mitral prosthetic regurgitation by transesophageal Doppler color flow imaging.In 165 patients with mitral valve prosthesis which were submitted for transesophageal echocardiography examination due to suspected prosthetic dysfunction, we studied 126 with pathological mitral regurgitation. On these patients, studies of jet spatial disposition, maximum width in its origin and severity quantification by means of maximum regurgitation area were performed.For the free jet group of patients (90), jet width at its origin correlated with maximal regurgitation area (r = 0.75); whereas for the wall jet group (36), the correlation degree was 0.59. We observed a relationship (p0.05) between severe mitral regurgitation assessed by maximal regurgitant jet size and jet widthor = 5 mm in both groups: the sensitivity and specificity of 72.7% and 95% respectively for free jets, and 70.7% and 64.4% for wall jets.The correlation between the area measurement and the width in its origin is better for free jets than for wall jets. A statistically significant relationship between the presence of severe mitral regurgitation and width in its originor = 5 mm could be observed, independently of the jet spatial disposition.

The aim of this study was to assess the long-term results of percutaneous transvenous mitral commisurotomy in our institution, and to evaluate potential predictors of long-term event-free survival.Between 1990 and 1996, 204 patients underwent percutaneous transvenous mitral commisurotomy with an Inoue balloon. One hundred and thirty two patients were followed for up to 9 months. Mean time of follow-up was 2.6-1.5 years (7 days-5.7 years). End points were considered mitral surgery, death and functional class III-IV. Long-term event-free survival analysis was performed to determine independent predictors of event-free survival.At the end of the study, 88% of patients were classified as New York Heart Association class I-II. Multivariate analysis revealed that independent predictors of major events were stiffness and thickening of the valve, presence of severe left atrial enlargement as factors pre-procedure; with suboptimal results and significant mitral regurgitation after percutaneous transvenous mitral commisurotomy.Percutaneous transvenous mitral commisurotomy with Inoue balloon is a safe and effective technique. Good results are maintained at long-term follow-up and the best results are obtained in patients with flexible and thin valves, with mild or moderate enlargement of left auricle and in cases with optimal results and without severe mitral regurgitation as a complication of the procedure.

The purpose of the study was to analyze some variables of donors, recipients and surgical procedures in order to discover factors that could predict mortality during the early stage (30 days) of orthotopic heart transplants.125 consecutive orthotopic heart transplants in adults were analyzed. The average age was 51 +/- 11 (range: 12-67), 109 (87%) were men, 16 were women (13%). Two groups were compared: 15 patients who died within 30 days after heart transplant and 110 who survived during that period. Immunosuppressive protocol: preoperative: Cyclosporin + Azathioprine. Intraoperative: Methylprednisolone Postoperative: Methylprednisolone (first 24 h), antilymphocyte monoclonal antibodies (7-10 days after heart transplant) + Cyclosporin + Azathioprine + Corticoids. The following parameters of the recipient were analyzed: sex, age, weight, size, thoracic perimeter, pretransplant cardiopathy, previous thoracic operations, functional stage or need for catecholamines during the days prior to the transplant, pulmonary artery pressure and resistance, history of systemic arterial hypertension, elevation of creatinine, blood type, urgent transplant indication, receptor/donor weight relationship. The following parameters of donors and operation were analyzed: sex, age, weight, thoracic perimeter, period in intensive care unit, dose of dopamine and dobutamine, blood type, origin of the organ, cause of death, ischaemia time, cardiopulmonary by-pass time and cardioplegia type.The rate of early mortality was 12%. The univariate analysis showed differences in: prior cardiovascular surgery, receptor blood type, need for urgent transplantation, pulmonary artery resistance2.5 Wood Units, cardiopulmonary by-pass time, weight relationship between receptor and donor. The death cause of the donor proved significant. On multivariate analysis, the following parameters independently predicted early mortality: history of operation with extracorporeal circulation, high pulmonary artery resistance, urgent transplant, receptor/donor weight relation and time of extracorporeal circulation.We believe that the results of our experience can help to stratify the risk in the orthotopic heart transplant recipient and even to contraindicate the procedure in some cases showing an accumulation of poor prognostic factors in borderline recipients.

We present the case of a 29-year-old women with a cardiac primary angiosarcoma diagnosis. The initial symptom was a cardiac tamponade. The tests for screening metastasis proved negative. She was preoperatively treated with chemotherapy, followed by a heart transplant. There were no incidents related to surgery nor to the transplant except for a rejection in the second week biopsy. Four weeks after the transplant, the patient had a sudden dyspnea, the radiological tests confirmed the existence of a massive pleural overflow and lung and pleural metastasis. All types of therapeutical approaches were rejected except for pleurodesis. The patient died 60 days after the heart transplant.

The purpose of this study was to analyze a series of variables in donors as well as of the preoperative and early and late postoperative of patients developing a right branch block of the bundle of His (RBBBH) in the first week after heart transplantation (HT), and to evaluate factors predicting the disappearance or progression of this conduction disorder.58 consecutive patients having undergone an orthotopic HT were studied. 15 of them showed a RBBBH after the HT (age: 43 +/- 13, 12 male, 3 female) and 43 did not (age: 54 +/- 17, 40 male and 3 female). ECGs and echocardiographic studies were performed after 1 week, 1, 3 and 6 months and 1 year. The following factors were analyzed: age and sex of the donor baseline cardiopathy, donor's weight related to recipient's weight, time of ischaemia and cardiopulmonary by-pass, number of rejections per patient/year, previous pulmonary vascular resistance. These parameters were compared among the patients who showed RBBBH and those who did not, and between those whose blocks disappeared in the follow-up and those whose blocks persisted.We found differences is the sex of donors, age of recipients, baseline etiology and time of cardiopulmonary by-pass (with block: 43 +/- 13 years old, dilated cardiomyopathy 73%, 106 +/- 25 minutes, whereas without block: 54 +/- 17 years old, dilated cardiomyopathy 42%, 92 +/- 18). The different parameters between the patients whose block underwent a regression or a progression were sex, lung resistances and right ventricle diameter (progression of the block: men 100%, 3.43% +/- 1.05 UW, progressively growing ventricular diameters. No progression or regression of the block: men 67%, 1.63 +/- 0.74 UW, ventricular diameters with progressive decrease).Younger recipients, with a diagnosis of dilated cardiomyopathy, to whom a woman's heart is implanted and who show a longer extracorporal circulation time are those who show a higher incidence of RBBBH: Male patients with high pulmonary resistances undergo a progressive increase in the diameter of the right ventricle and a progressive increase in the RBBBH degree.

The purpose of this study was to analyze the frequency of the different antigens of HLA in patients with diagnosis of very advanced dilated cardiomyopathy and ischemic heart disease by comparing them with a control group of supposedly healthy subjects.The group of dilated cardiomyopathy consisted of 35 patients (8 women and 27 men) aged between 14 and 60 years. The group of ischemic heart disease included 32 patients (4 women and 28 men) aged between 34 and 64 years. The control group comprised 1337 subjects of the Spanish Mediterranean area, supposedly healthy and recruited from paternity studies.In dilated cardiomyopathy we found a higher incidence in comparison with the control group of the A-2 (62.86% vs 46.22%), B-12 (60.00% vs 32.38%) and DQ-3 (82.86 vs 49.96%) antigens, and a lower incidence of B-51 (0.00% vs 12.49%). In ischemic heart disease we found, when comparing to the control group, a higher incidence of A-11 (31.25% vs 13.08%) and A-29 (34.38% vs 14.58%) antigens and a lower incidence of DQ-2 (15.63% vs 49.88%).In the Spanish Mediterranean area, the presence of A-2, B-12 and DQ-3 antigens, as well as the absence of B-51 would favour the appearance of advanced dilated cardiomyopathy. The presence of the A-11 and A-29 antigens would predispose to ischemic cardiomyopathy while the presence of DQ-2 would have a protective effect on the appearance of this cardiopathy.

The purpose of our study was to evaluate the usefulness of the isovolumetric relaxation time in both ventricles when diagnosing acute rejection in transplanted patients.68 endomyocardial biopsies were performed on a total of 38 patients. An echocardiographic study was carried out within the first 24 hours of each biopsy. All registrations were made by the same person. The isovolumetric relaxation time was measured in the left and right ventricles. The patients were divided according to two criteria: according to the degree of rejection (0-I, II, III) and according to whether the rejection was treatable (III) or non-treatable (0, I and II).In both ventricles, there was a progressive decrease of the isovolumetric relaxation time corresponding to higher degrees of rejection: in the left ventricle (0-I = 90 +/- 16; II = 74 +/- 16; III = 70 +/- 26; significant differences of II and III in relation to 0-I) as well as in right ventricle (0-I = 43 +/- 16; II = 37 +/- 14; III = 29 +/- 8; significant difference of III in relation to 0-I). The patients with treatable and non-treatable rejection were compared: no differences were found in the isovolumetric relaxation time of the left ventricle (0, I and II = 85 +/- 16 vs III = 70 +/- 26), but they were found in the right ventricle (0, I and II = 41 +/- 15 vs III = 29 +/- 8).Acute heart rejection induces a decrease of the isovolumetric relaxation time in both the left ventricle and the right ventricle. However, the isovolumetric relaxation time of the right ventricle seems to be a more useful parameter than isovolumetric relaxation time of the left ventricle, as it permits to detect whether an acute heart rejection is treatable or non-treatable.

The purpose of this study was to analyze the evolutionary changes of lipoprotein (a) levels occurring in heart transplant and to evaluate the possible relationship between the plasma concentration of this lipoprotein and the immunosuppressor drugs normally used in this type of transplant.17 patients undergoing heart transplant and with no history of dyslipemia or dysglucemia were studied. Patients with metabolic alterations after the transplant were excluded (except when these alterations occurred during the first week), as well as those who showed intercurrent processes near to the determinations. These were performed before the transplant, and 1, 2, 4 and 6 months later.An increase of lipoprotein (a) was observed after the transplant, with a subsequent progressive decrease. Significant differences were found between the levels prior to the transplant (9.18 +/- 8.66) and 6 months later (7.53 +/- 8.86), with no differences found between the previous concentrations and the determinations after one month (10.29 +/- 7.58), two months (8.06 +/- 7.90) and four months (8.82 +/- 7.84). Differences were also observed between the values of the first month in relation to the subsequent months, as well as between the 4th and the 6th month. No relationship was noticed between the levels of this lipoprotein and those of cyclosporin (r = 0.10), azatioprine (r = 0.17) and deflazacort (r = 0.19).The lipoprotein (a) levels increase after heart transplant, with a subsequent gradual decrease even below the previous figures. These levels bear no relationship with the dose of immunosupressors normally used in heart transplant.

INTRODUCTION AND PURPOSES: The purpose of this study was to check the beneficial effect of isosorbide-5-mononitrate (IS-5-MN) in patients with myocardial postinfarction silent ischemia, and to evaluate the possible appearance of tolerance after prolonged treatment.We have studied 20 patients, all males, with a history of infarction (11 with inferoposterior infarction and 9 with anterior infarction) and having a positive effort test by electrocardiographic criteria (ischemic S-T depression1 mm). The study was designed in two parts, first crossover with placebo, double-blind and then open during 100 days; until day 20, 40 mg/12 hours of IS-5-MN were administered and from then on 40 mg/8 hours of the drug. Effort tests were carried on days, 1, 20, 34 and 100, first basal ones and then at 3 and 6 hours after the administration of the medication.The time of S-T segment depression was prolonged in relation to the tests carried out with placebo and to its basal values (Placebo-basal: 235 +/- 97, Placebo-3 hours: 196 +/- 92, Placebo-6 hours: 201 +/- 80, day 1-basal: 197 +/- 84, day 1-3 hours: 420-96, day 1-6 hours: 381 +/- 93, day 20-basal: 221 +/- 81, day 20-3 hours: 384 +/- 121, day 20-6 hours: 389 +/- 112, day 34-basal: 272 +/- 91, day 34-3 hours: 437 +/- 102, day 34-6 hours: 362 +/- 100, day 100-basal: 269 +/- 102, day 100-3 hours: 389 +/- 112, day 100-6 hours 369 +/- 111). The duration of the effort was prolonged in relation to the placebo values (Placebo-basal: 480 +/- 100, Placebo-3 hours: 445 +/- 73, Placebo-6 hours: 430 +/- 79, day 1-basal: 450 +/- 95, day 1-3 hours: 510 +/- 79, day 1-6 hours: 532 +/- 86, day 20-basal: 524 +/- 93, day 20-3 hours: 535 +/- 77, day 20-6 hours: 519 +/- 77, day 34-basal: 517 +/- 85, day 34-3 hours: 567 +/- 87, day 34-6 hours: 558 +/- 94, day 100-basal: 520 +/- 89, day 100-3 hours: 593 +/- 91, day 100-6 hours: 590 +/- 92). This effect lasted throughout the 100 days of the study.Therefore, in patients with silent ischemia after myocardial infarction, the administration of 40 mg/12 hours as well as of 40 mg/8 hours of IS-5-MN shows an obvious anti-ischemic effect; with long-term treatment, the effect persists without evidence of tolerance phenomenon.

The purpose of this study was to evaluate the beneficial effects of transdermal nitroglycerine (TNG) in the treatment of superficial phlebitis caused by endovenous catheters and to compare them with the effects from the application of heparinoid substances. The study performed was prospective, randomized during a six-day period. One hundred patients (73 male and 27 female), aged 28-89 years (mean 67.3), participated in the study; all presented phlebitis, diagnosed by the presence of pain, erythema, edema, and fibrous cord in the area around the catheter. Among 50 subjects, two cm of NTG gel were administered to the affected zone once a day, and for the other 50 subjects, heparinoid substances were applied three times a day. The value parameters were: time for the disappearance of pain and time for reducing erythema, edema, and fibrous cord in half (all measured in hours). We found significant differences between the two treatments with TNG yielding greater improvement in terms of disappearance of pain (TNG: 50.2 +/- 39.7, heparinoids: 72.0 +/- 39.9), time for reducing erythema in half (TNG: 28.0 +/- 24.2, heparinoids: 54.6 +/- 34.5), and time for reducing fibrous cord in half (TNG: 58.3 +/- 38.4, heparinoids: 84.5 +/- 41.5). Edema was reduce before with TNG; however, this difference was not significant (TNG: 31.2 +/- 20.3, heparinoids: 33.0 +/- 25.7). We conclude that transcutaneous TNG should be applied systematically in patients with superficial phlebitis, given that it is more effective than the usual treatment with heparinoid substances.