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Spatiotemporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatiotemporal vena contracta complexity and its impact on MR severity grading.In 192 patients with suspected moderate or severe MR (100 primary MR [PMR]; 92 secondary MR [SMR]), we performed three-dimensional vena contracta area (VCA) quantification using single-frame (midsystolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns and with cardiac magnetic resonance (CMR) in a subset of cases (n = 20).The vena contracta was noncircular (shape index1.5) in 90% of patients. Severe noncircularity (shape index3) was more prevalent in SMR than in PMR (32.4% vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high grading agreement with VCAmean (83.3%). Pulmonary vein flow systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (area under the curve, 0.88, 0.86, and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as nonsevere by CMR more frequently compared with VCAmid and VCAmean.Highly prevalent spatiotemporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.

INTRODUCTION AND OBJECTIVES There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life. METHODS We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9±3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression. RESULTS At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05±2.4mm/m2, which increased significantly to 20.73±2.8mm/m2 (P

Background: Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). Methods: In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. Results: Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. Conclusions: There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.

Multicenter study [Abstract] Introduction and objectives: Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort. Methods: A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples. Results: A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R. Conclusions: This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR. [Resumen] Introducción y objetivos. Algunos estudios indican que los parámetros de strain por speckle-tracking pueden ser una alternativa no invasiva a la biopsia endomiocárdica para excluir el rechazo celular agudo (RCA) moderado o grave (≥ 2 R) tras el trasplante cardiaco (TxC). En una cohorte inicial, unos puntos de corte del 15,5% para el strain longitudinal global del ventrículo izquierdo (SLGVI) y el 17% para el strain de pared libre del ventrículo derecho mostraron un valor predictivo negativo del 100% para excluir RCA ≥ 2 R. Nuestro objetivo es analizar la utilidad del strain y validar estos puntos de corte en una cohorte multicéntrica prospectiva externa. Métodos. Estudio multicéntrico y prospectivo que incluyó a pacientes con seguimiento el primer año tras el TC. Se compararon los resultados de biopsias electivas con ecocardiogramas realizados el mismo día. Resultados. Se incluyó a 99 pacientes y 501 pares de biopsias-ecocardiogramas. El RCA ≥ 2 R en las biopsias fue del 7,4%. El SLGVI y el strain longitudinal de pared libre del ventrículo derecho fueron menores durante los RCA ≥ 2 R en el análisis univariante. En el análisis multivariante, el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. Los puntos de corte originales mostraron un valor predictivo negativo del 94,3% el RCA ≥ 2 R. Conclusiones. Este estudio mantiene un alto valor predictivo negativo para excluir RCA ≥ 2 R tras el TxC y el SLGVI se asoció de manera independiente con el RCA ≥ 2 R. El strain y, principalmente, el SLGVI pueden ser de utilidad en el diagnóstico y el tratamiento no invasivo del RCA.

Purpose Radiation exposure (RE) is a matter of concern for patients with congenital heart disease (CHD) who not infrequently need multiple interventional procedures under fluoroscopy guidance. We sought to evaluate the safety and feasibility of a minimally fluoroscopic approach in patients with CHD undergoing catheter ablation using a new image integration module (IIM). Methods Consecutive patients with CHD undergoing catheter ablation using the Carto Univu (TM) IIM were included. A near-zero fluoroscopy procedure was defined by an effective dose (ED)

Background In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models. Methods We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE. Results According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%–7.0%), compared with those without DVT (0.6%; 95% CI, 0%–3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0). Conclusions In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.

INTRODUCTION AND OBJECTIVES Pulmonary regurgitation (PR) is a frequent complication after repair of congenital heart disease. Lymphocyte expression of adrenoceptors (β1 and β2) and kinases (GRK2, GRK3, and GRK5) reflects the neurohumoral changes that occur in heart failure (HF). The main objective of this study was to describe the gene expression of these molecules in circulating lymphocytes in patients with severe PR. METHODS A prospective study was conducted to analyze lymphocyte expression of these molecules in patients with severe PR and compare it with expression in healthy controls and patients with advanced HF. RESULTS We studied 35 patients with severe PR, 22 healthy controls, and 13 patients with HF. Multiple comparisons analysis showed that β2-adrenoceptor gene expression levels were higher in the control group than in patients in the PR and HF groups and that expression in the latter 2 groups was similar (748.49 [rank 1703.87] vs 402.80 [rank 1210.81] vs 287.46 [rank 685.69] P = .001). Similar findings were obtained in gene expression of GRK2 (760.89 [rank 1169.46] vs 445.17 [rank 1190.69] vs 284.09 [rank 585.27] P < .001). There were no differences in expression levels of these molecules according to clinical variables in patients with PR. CONCLUSIONS The gene expression pattern of GRK2 and β2-adrenoceptor as molecular markers of cardiac dysfunction was altered in patients with severe PR compared with controls and was similar to expression in patients with advanced HF.

The prevalence of adults with congenital heart disease has dramatically increased during the last decades due to significant advances in the surgical correction of these conditions. As a result, patient's survival has been prolonged and arrhythmias have become one of the principal causes of morbidity and mortality for these patients. The surface 12-lead ECG may play a critical role in the identification of the underlying heart disease of the patient, the recognition of the arrhythmia mechanism and may also help in the planification of the ablation procedure in this setting. Finally, important prognostic information can be also obtained from the ECG in these patients. The present review will offer an overview of the principal utilities of the surface ECG in the diagnosis and management of patients with CHD and arrhythmias. (C) 2016 Elsevier Inc. All rights reserved.

Protein-losing enteropathy is a rare but life-threatening complication that occurs in some patients who develop intestinal lymphangiectasis secondary to increased systemic venous pressure. Although different forms of treatment have been tried, with varying results, the majority were reported to be unsuccessful. The aim of this study was to demonstrate that heart transplantation may be an appropriate therapeutic option for patients who do not respond to medical treatment. At our center, we performed heart transplantations in three patients with this condition. The mean follow-up period was 11+/-2 months. No patient died and the enteropathy regressed in all three.

Summary. Background: Cardiovascular risk factors for myocardial infarction (MI) are less frequent in younger than in older MI survivors. Therefore, the thrombotic component of MI may play a more important role at a young age. As activated protein C (APC) provides systemic anticoagulant and anti-inflammatory protection, a low plasma APC level may be an arterial thrombotic risk factor. Aim: To determine whether there is an association between reduced APC levels and early MI and severe coronary lesions. Methods: APC was measured in 231 young MI survivors and 231 controls. Results: Low APC levels were significantly associated with MI. Compared with the fourth quartile, the odds ratio (OR) for APC values in the first quartile was 3.7 [95% confidence interval (CI) = 2.1–6.4], and 3.2 (1.5–7.0) after adjustment for cardiovascular risk factors. Moreover, each decrease of 0.43 ng mL−1 (1 SD) in APC increased the OR 1.7 times (1.4–2.2), and 1.5 times (1.2–1.9) after adjustment for cardiovascular risk factors. Low APC levels were also associated with the number of coronary arteries affected and with the severity of coronary lesions (P

Background In renal transplantation, the degree of HLA matching has been reported to be negatively correlated with graft loss, with the number of rejections with complications. This association is less clear in heart transplantation, where there are contradictory studies, although most are consistent with those in renal transplantation. The objective of this study was to analyze differences in the probability of survival and the incidence of complications during follow-up according to the degree of HLA-A, -B, and -DR matching. Materials and methods Two hundred forty-three consecutive patients transplanted over a 13-year period were analyzed for age, gender, pretransplant factors associated with mortality, number of rejections and infections, incidence of acute graft failure, arterial hypertension, diabetes, and survival time with cause of death with reference to the number of HLA matches (zero to six). Exclusion criteria included retransplants, heart–lung transplants, pediatric transplants, and perioperative mortality. Groups were compared using the χ2 and ANOVA (Bonferroni posthoc test) tests. Kaplan-Meier survival curves were compared using the log rank test. The significance level was set at P Results The overall probability of survival of our series at 1, 5, and 10 years was 85%, 77%, and 60%, respectively. HLA-A, -B, and -DR compatibility: No significant differences were found when the curves were compared (log-rank: .005). The best survival rates were obtained with lower degrees of matching. No significant differences were found in the number of rejections or infections, although survival rates (P = .007) were higher among those with the lower degrees of matching. Conclusions A higher degree of HLA-A, -B, and -DR matching did not have a positive effect on heart transplant patient survival, rejection episodes or infections.

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.

Introduction and objectives Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. Methods We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. Results We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140 ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140 ms was found to be the only independent predictor of right ventricular dilation and dysfunction. Conclusions Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement.

Objective: The development of liver fibrosis and cirrhosis due to long-standing liver congestion is known to occur in adult patients with Fontan circulation. Hepatic elastography has shown to be a useful tool for the noninvasive assessment and staging of liver fibrosis in chronic liver diseases, although the utility of this technique in Fontan patients remains to be adequately studied. Methods: Twenty-one patients with Fontan circulation underwent an abdominal ultrasound and an acoustic radiation force impulse (ARFI) elastography. In order to compare the results from this group, a cohort of 14 healthy controls and another group containing 17 patients with cirrhosis were included. The association between the velocity values measured with elastography and clinical and analytical parameters were also studied. Results: Mean shear waves propagation velocity in liver tissue in the Fontan group was 1.86 ± 0.5 m/s, with 76% of patients over the cirrhosis threshold (1.55 m/s). The control group had a mean velocity of 1.09 ± 0.06 m/s, while the cirrhotic group obtained 2.71 ± 0.51 m/s. Seven patients with Fontan circulation had increased liver enzymes. Liver ultrasound showed evidence of chronic liver disease in six patients. Velocity values obtained in the presence or absence of analytical or liver ultrasound abnormalities showed significant differences in the univariate analysis ( P = .04 and P = .03 respectively). Conclusion: In conclusion, ARFI elastography showed increased wave propagation velocity values in the Fontan population suggesting increased liver stiffness which could be related to advanced fibrosis. A statistically significant association between ARFI values and the presence of analytical and ultrasound abnormalities has been demonstrated.

Background: Although dilated cardiomyopathy (DCM) is a disease of unknown and probably multifactorial etiology, a change in immune mechanisms is presumably significant, with many abnormalities in humoral and cellular responses having been reported. The heart thus becomes the target organ for an initial episode of myocardial damage that triggers an autoimmune response. Hypothesis: The purpose of this study was to analyze the frequency of different human leukocyte antigens in patients with a diagnosis of well-advanced DCM and ischemic heart failure, comparing them with a control group of presumably healthy subjects. Methods: The group with dilated cardiomyopathy consisted of 50 patients (7 women and 43 men), aged from 14 to 64 years. The group with ischemic heart disease included 76 patients (4 women and 72 men), with ages ranging from 34 to 64. The control group, consisting of 1,337 presumably healthy subjects from the Spanish Mediterranean area, was recruited based on paternity studies. Results: Compared with the control group, we found in DCM a greater incidence of B15 (20 vs. 6%) and DQ 3 (83 vs. 50%) antigens. In ischemic heart disease we found a lower incidence of A1 (3 vs. 22%), B8 (5 vs. 12%), and DQ2 (16 vs. 50%) in comparison with the control group. Conclusions: In the Spanish Mediterranean area, the presence of antigens B-15 and DQ3 would be associated with advanced DCM. The absence of antigens A1, B8, and DQ2 would be associated with the occurrence of severe ischemic heart disease.

Background Brain naturietic peptide (BNP) elevations have been reported in heart transplant patients both at baseline and during rejection. An association between BNP levels and certain echocardiographic and hemodynamic abnormalities has also been found in nontransplanted heart disease patients. We sought to determine whether BNP values were correlated with echocardiographic and hemodynamic parameters among a large cohort of heart transplant patients. Materials and methods We studied 71 consecutive heart transplant patients, excluding combined grafts, retransplants, and pediatric cases. We performed 488 BNP determinations during catheterization and within 48 hours of echocardiography. Hemodynamic parameters included mean pulmonary artery pressure, right ventricular systolic and diastolic pressures. Doppler echocardiography parameters were wall thickness, ventricular mass, left and right ventricular end-diastolic and end-systolic diameters, isovolumic relaxation time, and mitral flow deceleration time. Results We observed significant correlations between BNP values and left ventricular size, ventricular mass, and a restrictive filling pattern. BNP levels were also significantly correlated with right ventricular size, mean pulmonary artery pressure, and right ventricular diastolic and end-diastolic pressures. Conclusions In heart transplant patients, BNP levels positively correlated with ventricular diameters and a restrictive filling pattern. An increase in right ventricle and pulmonary artery pressures was associated with elevated BNP values.

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.

Left ventricular free wall rupture and acute ischaemic mitral regurgitation are nowadays rare, but still potentially lethal mechanical complications after acute myocardial infarction. We report a case of a sequential left ventricular free wall rupture, anterolateral papillary muscle disruption, secondary severe mitral regurgitation and subsequent posteromedial papillary muscle head rupture in a single patient during the same ischaemic episode after myocardial infarction, and their related successful surgical procedures and management until discharge. Prompt bedside diagnosis and emergent consecutive surgical procedures, as well as temporary left ventricular assistance, were crucial in the survival of this patient.

The purpose of this study was to evaluate whether high levels and small isoforms of lipoprotein (a) [Lp(a)] are markers of risk of early myocardial infarction and markers of the severity of coronary atherosclerosis. Lp(a) levels and small apo(a) isoforms were higher in 222 patients than in 199 controls (p0.001). In patients, Lp(a)or =30 mg/dL was associated with the presence of coronary lesions (p=0.007) and the severity of coronary atherosclerosis (p=0.002). The present study suggests that Lp(a) levels and small isoforms are markers of early myocardial infarction and that Lp(a) levelsor =30 mg/dL are associated with severe patterns of coronary atherosclerosis.

Background and aims. Immunosuppressive therapy has undergone great changes in recent years as a result of the introduction of new drugs, presumed a prior 2 to be more effective and better tolerated. The greatest advance seems to have been the introduction of interleukin-2 (IL-2) receptor antagonists. The objective of this study was to determine whether the use of IL-2 receptor antagonists in induction therapy has implications for the development of rejection and survival. Materials and methods. Three hundred sixty-five consecutive cardiac transplant patients who received induction therapy were included. Heart-lung and transplants in children under 10 years were excluded. Three groups were compared according to the induction therapy (OKT3, 10 days; OKT3, 7 days; and IL-2R antagonists). Each treatment corresponded to a time period: OKT3 10 days from June 1989 to April 1994; OKT3 7 days from May 1994 to October 2002; and IL-2R antagonists from November 2002 to May 2004. Baseline characteristics of recipient and donor, surgical times, postsurgical complications, maintenance immunosuppression, number of rejections, time (days) to first rejection, and probability of survival at 1 year were recorded. We used analysis of variance, X 2 test, Kaplan-Meier curves, and log-rank test as appropriate. A P-value

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.

A prospective study of 81 heart transplant (HT) patients was carried out in order to evaluate the evolution of brain natriuretic peptide (BNP) levels in HT patients and compare them with the degree of rejection as determined by endomyocardial biopsy. All patients were subjected to endomyocardial biopsy (532), and determination of BNP and creatinine levels as well as hemodynamic parameters. A control group of 36 volunteers was included. BNP values were significantly greater in HT patients than in healthy volunteers. In the first 3 months, BNP levels in patients with treatable rejection were significantly greater than in patients without graft rejection, although evident overlapping was observed in both distributions and discriminatory potential was low. After the third month, BNP values were similar in patients with and without rejection. Creatinine levels were observed to increase over time after transplantation, but no correlation was observed between the creatinine and BNP levels. A significant positive correlation was observed between BNP and right ventricle and pulmonary arterial pressures.

Thrombin-activatable fibrinolysis inhibitor (TAFI) is a fibrinolytic inhibitor. Studies in coronary artery disease have reported increased TAFI activity (TAFI Act) and low TAFI antigen (TAFI Ag) levels. This controversy might be explained by the polymorphisms of its gene. Only the Thr325Ile polymorphism modulates both TAFI Ag and Act levels in vitro. This study assessed TAFI Ag and Act levels, TAFI Thr325Ile polymorphism, the fibrinolytic and protein C systems and some prothrombotic mutations in a young patient group (n = 127, aged51 years, with myocardial infarction) and a control group (n = 99) with similar characteristics. Patients exhibited hypofibrinolysis and higher plasminogen activator inhibitor-1 (PAI-1) levels. Although TAFI Ag was lower, TAFI Act level was significantly higher in patients and positively correlated with PAI-1, protein C inhibitor and the euglobulin lysis time. No differences between groups were found according to the Thr325Ile polymorphism. Irrespective of the genotype, patients had higher TAFI Act levels. The Ile-325 variant exhibited lower TAFI Ag levels. We suggest that the hypofibrinolysis observed in these patients results from an increase in both PAI-1 and TAFI Act, which is not related to the Thr325Ile polymorphism. Patients have high TAFI Act with low TAFI Ag levels, probably because of an increased stability of TAFI related to a fibrinolytic hypofunction.

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

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.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.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).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.

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.

In recent years, the relation between biological markers of inflammation and prognosis in patients suffering from acute coronary syndromes has been investigated. The aim of this study was to evaluate the association between baseline fibrinogen concentrations and the development of clinical events in patients admitted with suspicion of unstable angina and non-Q-wave myocardial infarction.Levels of fibrinogen at enrollment were analyzed in 325 consecutive patients with acute coronary syndromes. Fibrinogen values were divided into tertiles and the incidence of clinical events was evaluated at each level. The combination of death and/or myocardial infarction was the main endpoint.Fibrinogen levels were significantly higher in patients who subsequently had myocardial infarction, cardiac death, or both during follow up. The probabilities of death and/or myocardial infarction were 6%, 13%, and 29% (p0.0001), respectively, in patients grouped by fibrinogen tertiles (304, 305-374 and 375 mg/dl). Multivariate predictors of combined events were age, previous angina, ST-segment depression in the admission ECG, and fibrinogen into tertiles. The adjusted hazard ratio (95% CI) for patients in the upper tertile was 4.8 (1.6-14; p = 0.004).High fibrinogen levels were related to a less favorable long-term or short-term outcome in patients admitted for suspicion of unstable angina and non-Q-wave myocardial infarction. This association persists after adjustment for other classical risk factors such as age, prior angina, and ST-segment depression in the ECG.

HEART TRANSPLANTATION (HT) is presently the treatment of choice for severe heart disease in patients presenting poor clinical conditions who are not amenable to alternative therapy. The increase in posttransplant survival, particularly following the introduction of cyclosporine, has led to an increasing number of patients who survive for long periods of time. However, all such patients require chronic maintainance immunosuppressive therapy to reduce the incidence and severity of graft rejection. Most centers use a triple therapy protocol consisting of cyclosporine, azathioprine, and steroids. Since immune activity and the tendency toward rejection is greater in the first months after transplantation, most regimens administer higher doses in the early stages, followed by a gradual reduction to maintenance levels. However, despite the use of increasingly lower doses, the morbidity associated with immunosuppressive drugs remains high. The present study investigated the frequency and progression of side effects produced by immunosuppressive medication continuously administered to patients following HT.

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.

Right ventricular infarction usually occurs in association with inferior infarction, with no remarkable electrocardiographic signs in conventional leads. This report describes a patient with a previous inferior acute myocardial infarction who developed right ventricular infarction with significant anterior lead ST segment elevation (V1–V4) caused by the loss of two large right ventricular branches during a coronary angioplasty of the right coronary artery. The case is discussed and the literature is reviewed.