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La Seccion de Insuficiencia Cardiaca, Trasplante Cardiaco y otras Alternativas Terapeuticas de la Sociedad Espanola de Cardiologia desarrollo en Sevilla, en junio de 2005, una Conferencia de Consenso sobre trasplante cardiaco (TC) a la que fueron invitados a participar todos los grupos espanoles de TC. El objetivo fue determinar, discutir y consensuar los aspectos mas relevantes y/o controvertidos de diferentes areas del TC en la actualidad: organizacion, seleccion del receptor, donantes, rechazo, inmunosupresion, enfermedad vascular del injerto, complicaciones a largo plazo y TC pediatrico. Este documento reune las recomendaciones del grupo de trabajo incluyendo el grado de evidencia con que se respalda cada una.

Barge-Caballero, E., Segovia-Cubero, J., Gonzalez-Vilchez, F., Delgado-Jimenez, J., Perez-Villa, F., Almenar-Bonet, L., Arizon-Del Prado, J.L., Lage-Galle, E., De La Fuente-Galan, L., Manito-Lorite, N., Sanz-Julve, M., Villa-Arranz, A., Lambert Rodriguez, J.L., Brossa-Loidi, V., Pascual-Figal, D., Muniz-Garcia, J., Crespo-Leiro, M.

s S113 S. Rao , C. Hayward, P. MacDonald, A. Jabbour, E. Kotlyar, A. Keogh. Heart and Lung Transplantation Unit, St Vincent’s Hospital, Sydney, Australia. Purpose: Since the broadening of age eligibility criteria for orthotropic heart transplantation (OHT) in 2006, there has been an increase in the number of transplants being performed in recipients 60 years and older. Outcomes for older patients have not been reassessed since this guideline change has occurred. Methods: We retrospectively reviewed the UNOS dataset to identify first time OHT recipients from 2006 onwards (n= 18,130). All cause mortality was assessed and modelled using Kaplan-Meier method, and comparison was made between those aged more 60 years vs 18-59 years. Further analysis within the older age group was performed between the 60 to 64 years, 65 to 70 years and ≥ 70 years. Results: Of the 18,130 patients identified, 35% were aged 60 years or more (n= 6,454). Within the older group, 53% were aged 60-64 (n= 3,420), 39% were aged 65-69 (n= 2,505) and 8% were aged 70 or older (n= 529). Survival at 30 days, 1 year and 5 years was 96%, 90% and 79% for the younger group and 96%, 88% and 77% for the older group (p < 0.001). There was no significant difference in survival within the older group (see table, p = 0.18). Conclusion: Recipient age has minimal impact on 5-year survival after heart transplantation in the current era. Broadening the transplant eligibility criteria for OHT has led to an increase in the number of OHT performed in older recipients; however appropriate selection of older patients has led significant improvement in survival in this group such that it now is similar to outcomes for younger patients prior to 2006.

Introduction. Primary pulmonary hypertension and its associated forms is a progressive and often fatal disease, the course of which has been favourably modified by prostacyclin therapy in the last decade. Objective. The aim of this study is to analize retrospectively the efficacy of continuous intravenous epoprostenol (synthetic prostacyclin) therapy in pulmonary arterial hypertension, and to compare it with conventional therapy (anticoagulants, digoxin and diuretics). Methods. Between 1990-2000, 31 patients with severe precapillary pulmonary hypertension in functional class III or IV went on continuous intravenous epoprostenol therapy, administered by a portable infusion pump through a Hickman catheter. We compared their survival with a group of 16 patients treated with conventional therapy alone. Results. Time of follow-up was 33.25 months in the prostacyclin group and 20 months in the conventional group. The one- three- and five- year survival rates were 86%, 50% and 38% respectively for patients treated with epoprostenol compared with 40%, 40% and 8% survival rates at idetical periods for patients treated conventionally (p = 0,02). Functional class and the mean distance walked in the 6 minutes test were improved in patients treated with prostacyclin (p < 0,01). Serious complications attributable to the delivery system included 3 deaths, mainly due to infection. Conclusion. Continuous intravenous epoprostenol therapy improves survival and exercise capacity in patients with severe pulmonary arterial hypertension despite potentially serious complications attributable to the delivery system.

Background A number of changes in the management of heart transplantation (HT) patients have each tended to reduce the risk of post-HT hematologic cancer, but little information is available concerning the overall effect on incidence in the HT population. Methods Comparison of data from the Spanish Post-Heart-Transplantation Tumour Registry for the periods 1991–2000 and 2001–2010. Results The incidence among patients who underwent HT in the latter period was about half that observed in the former, with a particularly marked improvement in regard to incidence more than five yr post-HT. Conclusions Changes in HT patient management have jointly reduced the risk of hematologic cancer in the Spanish HT population. Long-term risk appears to have benefited more than short-term risk.

[Abstract] Objectives. We sought to investigate the potential impact of preoperative short-term mechanical circulatory support (MCS) with extracorporeal devices on postoperative outcomes after emergency heart transplantation (HT). Methods. We conducted an observational study of 669 patients who underwent emergency HT in 15 Spanish hospitals between 2000 and 2009. Postoperative outcomes of patients bridged to HT on short-term MCS (n = 101) were compared with those of the rest of the cohort (n = 568). Short-term MCS included veno-arterial extracorporeal membrane oxygenators (VA-ECMOs, n = 23), and both pulsatile-flow (n = 53) and continuous-flow (n = 25) extracorporeal ventricular assist devices (VADs). No patient underwent HT on intracorporeal VADs. Results. Preoperative short-term MCS was independently associated with increased in-hospital postoperative mortality (adjusted odds-ratio 1.75, 95% CI 1.05–2.91) and overall post-transplant mortality (adjusted hazard-ratio 1.60, 95% CI 1.15–2.23). Rates of major surgical bleeding, cardiac reoperation, postoperative infection and primary graft failure were also significantly higher among MCS patients. Causes of death and survival after hospital discharge were similar in MCS and non-MCS candidates. Increased risk of post-transplant mortality affected patients bridged on pulsatile-flow extracorporeal VADs (adjusted hazard-ratio 2.21, 95% CI 1.48–3.30) and continuous-flow extracorporeal VADs (adjusted hazard-ratio 2.24, 95% CI 1.20–4.19), but not those bridged on VA-ECMO (adjusted hazard-ratio 0.51, 95% CI 0.21–1.25). Conclusions. Patients bridged to emergency HT on short-term MCS are exposed to an increased risk of postoperative complications and mortality. In our series, preoperative bridging with VA-ECMO resulted in comparable post-transplant outcomes to those of patients transplanted on conventional support.

Primary pulmonary hypertension is a progressive disease. Most affected patients are young and middle-aged women. Etiology is unknown, although a familial and genetic factor is present in up to 6% of cases. Endothelial dysfunction and abnormalities in calcium channels of smooth muscle fibers are the present pathogenetics theories. Diagnostic tests try to exclude secondary causes of pulmonary hypertension and to evaluate its severity. Acute vasodilatory test is vital in the selection of treatment. Oral anticoagulation is indicated in all patients. Lung transplant is performed when medical treatment is unsuccessful. Atrial septostomy is an alternative and palliative treatment for selected cases. Chronic thromboembolic pulmonary hypertension is a special form of secondary pulmonary hypertension, clinically undistinguishable from primary primary hypertension, is of mandatory diagnosis because it can be cured with thromboembolectomy. Pulmonary embolism is common in hospitalised patients. The mortality rate for pulmonary embolism continues to be high: up to 30% in untreated patients. The accurate detection of pulmonary embolism remains difficult, as pulmonary embolism can accompany as well as mimic other cardiopulmonary illnesses. Non-invasive diagnostic tests have poor specificity and sensitivity. The D-dimer level and the spiral CT angiography have also been employed as new alternatives and important tools for precise diagnosis of suspected pulmonary embolism. The standard therapy of pulmonary embolism is intravenous heparin for 5 to 10 days in conjunction with oral anticoagulants posteriorly for 3 to 6 months. The incidence of deep venous thrombosis, pulmonary embolism and death due to pulmonary embolism, can be reduced significantly and shown clear benefits only by adoption of a prophylactic strategy with low-molecular-weight-heparins or dextrans in patients at risk.

La prostaciclina mejora los sintomas, la capacidad de ejercicio y la supervivencia en los pacientes con hipertension arterial pulmonar. Sin embargo, sus complejas vias de administracion (intravenosa, inhalada, subcutanea) ocasionan frecuentes efectos adversos que disminuyen la calidad de vida y pueden ser graves. Bosentan, un antagonista oral de los receptores de la endotelina, mejora la clase funcional y la capacidad de ejercicio en estos pacientes. Describimos la transicion de prostaciclina a bosentan en 5 pacientes con hipertension arterial pulmonary severa e importantes complicaciones secundarias al tratamiento con prostaciclina.

Prostacyclin improves symptoms, exercise tolerance, and survival in patients with pulmonary arterial hypertension. However, the difficulty of administration (whether intravenous, subcutaneous, or by inhalation) often causes side effects that can reduce the patient's quality of life and which may sometimes be serious. Bosentan, an orally active endothelin receptor antagonist, improves functional class and exercise tolerance in these patients. We describe the successful transition from prostacyclin to bosentan in five patients with severe pulmonary arterial hypertension who suffered serious side effects with prostacyclin treatment.

Background— Postoperative outcomes of patients with advanced heart failure undergoing ventricular assist device implantation are strongly influenced by their preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles. We sought to investigate whether a similar association exists in patients undergoing emergency heart transplantation. Methods and Results— By means of the Spanish National Heart Transplant Registry database, we identified 704 adult patients treated with emergency heart transplantation in 15 Spanish centers between 2000 and 2009. Post-transplant outcomes were analyzed pertaining to patient preoperative INTERMACS profiles, which were retrospectively assigned by 2 blinded cardiologists. Before transplantation, INTERMACS profile 1 (critical cardiogenic shock) was present in 207 patients, INTERMACS profile 2 (progressive decline) in 291, INTERMACS profile 3 (inotropic dependence) in 176, and INTERMACS profile 4 (resting symptoms) was present in 30 patients. In-hospital postoperative mortality rates were, respectively, 43%, 26.8%, and 18% in patients with profiles 1, 2, and 3 to 4 ( P P =0.03) and postoperative need for dialysis (1: 33.2%, 2: 18.9%, 3–4: 21.5%; P Conclusions— Preoperative INTERMACS profiles determine outcomes after emergency heart transplantation. Results call for a change in policies related to the management of heart transplant candidates presenting with INTERMACS profiles 1 and 2.

[Abstract] In this study we analyzed Spanish Post-Heart-Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post-HT follow-up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post-HT. Incidence increased with age at HT from 149 per 100 000 person-years among under-45s to 542 among over-64s; was 4.6 times greater among men than women; and was four times greater among pre-HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age-at-diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan–Meier 2−year survival to 70% versus 16% among inoperable patients.

[Abstract] Introduction. Malignancy is a major complication in the management of solid organ transplant patients. Skin cancers show a better prognosis than other neoplasms, but not all others are equal: Ideally, patient management must take into account the natural history of each type of cancer in relation to the transplanted organs. We sought to determine the prognosis of various groups of noncutaneous nonlymphomatous (NCNL) cancers after heart transplantation (HT). Methods. We retrospectively analyzed the records of the Spanish Post-Heart-Transplant Tumour Registry, which collects data on posttransplant tumors in all patients who have undergone HT in Spain since 1984. Data were included in the study up to December 2008. We considered only the first NCNL post-HT tumors. Results. Of 4359 patients, 375 developed an NCNL cancer. The most frequent were cancers of the lung (n = 97; 25.9%); gastrointestinal tract (n = 52; 13.9%); prostate gland (n = 47; 12.5%; 14.0% of men), bladder (n = 32; 8.5%), liver (n = 14; 3.7%), and pharynx (n = 14; 3.7%), as well as Kaposi's sarcoma (n = 11; 2.9%). The corresponding Kaplan-Meier survival curves differed significantly (P < .0001; log-rank test), with respective survival rates of 47%, 72%, 91%, 73%, 36%, 64%, and 73% at 1 year versus 26%, 62%, 89%, 56%, 21%, 64%, and 73% at 2 years; and 15%, 51%, 77%, 42%, 21%, 64%, and 52% at 5 years post-diagnosis, respectively. Conclusion. Mortality among HT patients with post-HT NCNL solid organ cancers was highest for cancers of the liver or lung (79%–85% at 5 years), and lowest for prostate cancer (23%).

Primary sarcoma of the pulmonary artery (PSPA) is extremely rare. Many cases are misdiagnosed as pulmonary arterial hypertension (PAH) because of chronic thromboembolic disease (CTD). Four cases of PSPA with the initial misdiagnosis are reported. The presence of a unique mass in the main pulmonary artery or proximal branches, rapidly progressive dyspnea, and constitutional symptoms should raise the suspicion of PSPA. The pathological diagnosis is usually confirmed during surgery, which is done along with adjuvant chemotherapy, the treatment of choice.

Primary pulmonary hypertension and its associated forms is a progressive and often fatal disease, the course of which has been favourably modified by prostacyclin therapy in the last decade.The aim of this study is to analize retrospectively the efficacy of continuous intravenous epoprostenol (synthetic prostacyclin) therapy in pulmonary arterial hypertension, and to compare it with conventional therapy (anticoagulants, digoxin and diuretics).Between 1990-2000, 31 patients with severe precapillary pulmonary hypertension in functional class III or IV went on continuous intravenous epoprostenol therapy, administered by a portable infusion pump through a Hickman catheter. We compared their survival with a group of 16 patients treated with conventional therapy alone.Time of follow-up was 33.25 months in the prostacyclin group and 20 months in the conventional group. The one- three- and five- year survival rates were 86%, 50% and 38% respectively for patients treated with epoprostenol compared with 40%, 40% and 8% survival rates at idetical periods for patients treated conventionally (p = 0,02). Functional class and the mean distance walked in the 6 minutes test were improved in patients treated with prostacyclin (p0,01). Serious complications attributable to the delivery system included 3 deaths, mainly due to infection.Continuous intravenous epoprostenol therapy improves survival and exercise capacity in patients with severe pulmonary arterial hypertension despite potentially serious complications attributable to the delivery system.

We report a case of angiosarcoma of the heart, manifested as a continuous murmur. Right coronary arteriography disclosed a paracardiac mass with fistulas from the coronary vessel to the right atrium. Histologic study revealed this to be an angiosarcoma with sinusoidal pattern. To our knowledge, this is the first case of this kind of cardiac tumor presenting as a fistula from a coronary artery to the right atrium.

Background: For many years, high-emergency cardiac re-transplantation (HE-CR) has been considered as the choice therapeutic option for patients with irreversible primary graft failure during the early postoperative period of a previous heart transplantation (HT). HE-CR is also occasionally considered for HT patients in a critical clinical condition due to late graft failure secondary to chronic rejection. Aims: To describe the early postoperative and long-term outcomes of patients undergoing HE-CR and to compare them with those of patients undergoing a first heart transplantation under a high-emergency status (FHT-HE). Methods: Multicenter registry including 711 patients aged >18 who underwent high-emergency HT between January 1, 2000 and December 31, 2009 in fifteen out of the sixteen hospitals provided with an adult HT program. All patients suffered from severe cardiac failure depending on intravenous inotropes or mechanical circulatory support, or complicated with refractory arrythmic storm. Data were collected from the National Heart Transplant Registry database and clinical records. Early postoperative outcomes and long-term survival of HE-CR and FHT-HE patients were compared. Data on patients' vital status were available as for October 31, 2010. Kaplan-Meier post-transplant long-term survival curves were estimated, and then compared by means of the log-rank test. Results: 31 (4.5%) patients underwent HE-CR and 680 patients underwent FHT-HE. Mean age was 50 years, and 20% were women. No significant differences regarding basal clinical characteristics of recipients or donors were observed between the two groups, with the exception that HE-CR patients showed a higher mean serum creatinin (1.7±0.7 versus 1.3±0.7 mg/dl, p=0.01). The proportion of patients supported on a short-term VAD was 26% in the HE-CR group and 15% in the HE-FHT group (p=0.09). During the early postoperative period, the HE-CR group presented significantly higher rates of major surgical bleeding (48% versus 24%, p=0.02), primary graft failure (52% versus 24%, p