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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 and purpose: Right ventricular dysfunction (RVD) has been described as an independent factor for morbidity and/ or mortality in various nosological entities. However, there are no data on its true

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.

Aim. To undertake an evolutionary analysis of echocardiographic examinations carried out during follow-up of cardiac transplant patients. Materials and methods. The study included 193 consecutive patients transplanted between August 1998 and December 2004. We excluded pediatric, cardiopulmonary, and repeat transplants. Four echocardiographic examinations were analyzed per patient (first, second, third quarter and the last study carried out; average time from transplant: 1115 ± 681 days). The total number of examinations was 772. The evaluated variables were thickness of walls and diameters of the cavities, systolic and diastolic functions, pericardial effusion, and number of rejections. Results. The isovolumetric relaxation time showed reduced values during early echocardiography with subsequent increases during evolution (first echocardiogram: 92 ± 16 vs final echocardiogram 101 ± 16 ms; P

Background: Activated protein C (APC) is an enzyme with anticoagulant and cytoprotective functions. Accumulative data suggest that the number of situations in which in vivo circulating APC will need to be measured will increase over the next few years. Therefore, the availability of a rapid, sensitive and simple assay for quantifying circulating APC is crucial. Available assays are difficult to apply in routine laboratory. Our previously reported assay required an excessive pre-analytical handling: drawing of blood into two citrate tubes; immediate addition of a fresh APC inhibitor to one tube in order to block complexation of circulating APC to protein C inhibitor (PCI), and of heparin to the other tube to force all circulating APC to bind to PCI, and measurement of APC:PCI complexes in both tubes by ELISA (method A). Here we describe a simplifiedmethod based on the measurement of APC:PCI in a unique blood tube anticoagulated with heparin (method B). Methods: We measured APC levels, with both methods, in 125 plasma samples, 69 from patients with venous thrombosis (VT) and 56 from healthy controls. Results: ThemeanAPC level in the 125 sampleswas 1.06±0.46 ng/ml (method A) and 2.21±0.85 ng/ml (method B). The coefficient of correlation between both methods was r=0.849 (Pb0.001). The mean APC level in the 69 VT patients wase 0.84±0.38 (method A) and 1.80± 0.67 (method B), significantly lower (as previously reported) than those in the 56 controls, 1.33±0.39 and 2.72±0.79, respectively, (Pb0.001). In both groups there was a significant correlation between the levels obtained by the two methods (VT, r=0.772; controls, r=0.777 (Pb0.001). Comment: These results show that both assays are equivalent, and confirm that the APC level is lower in VT patients than in healthy individuals. Therefore, the new simplified assay, which measures the sum of circulating free APC and APC complexed to PCI, may be used to estimate the level of circulating APC, and will allow its use in routine laboratories. (FIS PS09/00610, RECAVA RD06/0014/0004, Prometeo/ 2011/027, y Fundacion para la Investigacion Hospital La Fe; Pilar Medina is a Miguel Servet Researcher, ISCIII CP09/00065).

La endocarditis infecciosa precoz es una complicacion grave que se observa en el 3% de los pacientes portadores de protesis valvulares cardiacas y que sigue teniendo una mortalidad muy elevada. Aparece antes de los 12 meses del recambio valvular, es mas agresiva que la tardia, y esta producida fundamentalmente por estafilococos. Las manifestaciones clinicas estan relacionadas con la presencia de bacteriemias asociadas a signos de dehiscencia protesica. Presentamos un caso de endocarditis protesica precoz en posicion aortica complicada con insuficiencia aortica severa y fistula entre raiz aortica y auricula derecha, junto con alteracion electrocardiografica consistente en trastorno de la conduccion auriculoventricular e intraventricular.