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Objective: Bone loss and bone fractures are disabling complications after heart transplantation. Severe bone loss happens mainly during the first year posttransplantation. Steroids and cyclosporine alter bone metabolism in several ways. To counterbalance these effects, antiresorptive therapy is provided to these patients. The objective of this study was to assess the frequency of bone fractures after heart transplantation, considering previous comorbidities, immunosuppressive therapy, and osteoprotective treatment. Methods: From 1993 to 2005, 443 consecutive heart transplant recipients were followed for the occurrence of bone fractures, immunosuppressive therapy, clinical conditions, and antiresorptive treatment. Results: There were 41 fractures in 34 patients (7.6%, group I). The remainder of patients formed group II. Fractures commonly involved the lumbar spine. Postmenopausal women had more fractures than other patients (20.6% vs 7.8%, P = .02). When the initial immunosuppressive regimen included tacrolimus, fractures did not happen (P = .01, vs other regimens). Osteoprotective therapy was administered to 91.2% of patients in group I and 79% in group II (P = .08). Mean interval from transplantation to the first fracture was 1131.5 days. Overweight patients had a 61.8% incidence of fracture. Conclusions: Our series showed a low frequency of bone fractures. Postmenopausal women and overweight patients had more fractures. An initial immunosuppressive regimen using tacrolimus was associated with lower fracture rates., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Objectives: Apical ballooning shares features with acute coronary syndromes. Recently, atypical forms have been reported without apical involvement. Usually, the prognostic reports have compared them with ST-segment elevation infarction. Left ventricular transient dyskinesias (LVTD), however, frequently occur without ST-segment elevation and when present, these patients always have open arteries. Our aim was to assess the baseline features, clinical presentation, natural history and compare long-term prognosis in an LVTD-cohort with a first non-ST-segment elevation acute coronary syndrome (NSTEMI) group. Methods: We performed a prospective observational study including consecutive patients in two groups: (i) LVTD group: 62 patients with this syndrome between 2003 and 2007. Inclusion criteria were LV segmental transient motion abnormalities; ECG new alterations and elevated troponin; absence of recent significant head trauma or obstructive coronary artery lesions. (ii) Control group: 169 patients admitted for a first NSTEMI in 2004. Results: Median follow-up was 35 months. Mean age was 65 years. LVTD group included 83.9% females. NSTEMI group was predominantly males. Eleven in-hospital deaths happened in NSTEMI cohort and none in LVTD. Four patients in the LVTD group required readmission and two patients died. In the NSTEMI group, heart failure, unstable angina, myocardial infarction (P<0.001) and death (P=0.11) were more frequent. Cox regression showed that diabetes mellitus, significant onset mitral regurgitation and NSTEMI versus LVTD were found as event-independent predictors. Conclusion: LVTD diagnosis represents a decreased risk of events when compared with classic non-ST-segment acute coronary syndrome, pointing out a different pathophysiologic mechanism., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Apical transient left ventricular diskynesia is a recently described entity able to imitate acute coronary syndrome. The presence of previous coronary artery disease (CAD) is an exclusion criterion for this diagnosis in several studies. We report the case of a sixty-three year-old-caucasian man with previously known CAD, left anterior descending artery (LAD) stented-disease, presenting in the emergency room with angina and ST-segment elevation. A coronariography was urgently performed. No new coronary lesions could be demonstrated. LAD-placed stents were patent and showed no change in their angiographic appearance. Left ventriculogram demonstrated apical diskynesia (Takotsubo-like). Complete and rapid resolution of left ventricular dysfunction was echocardiographycally displayed seven days later. Months after, coronary lesions increased associated with new acute coronary syndromes and new revascularization procedures were required. The present case supports the idea that CAD and apical transient diskynesia could coexist in the same patient, arising further questions about the pathophysiology, prognosis and management of the latter., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Background: The Killip classification categorizes heart failure (HF) in acute myocardial infarction, and has a prognostic value. Although non-ST-elevation myocardial infarction (NSTEMI) is increasing steadily, little information is available about the prognostic value of low Killip class in this scenario. Our aim was to assess the prognostic value of mild HF in NSTEMI. Methods: 835 patients with NSTEMI between 2005 and 2007 were prospectively recruited. Patients in Killip-1 (K1=684) or Killip-2 class (K2=113) were selected (38, with K>2, excluded). Clinical, angiographic, treatment strategies, and 30-day all-cause mortality, together with other cardiovascular outcomes were recorded. Results: K2 patients were mostly women (K1 27.9% vs K2 48.0%, p<0.001) and older (K1 66.6years vs K2 73.8years, p<0.001) with a higher frequency of diabetes mellitus (p<0.001) and hypertension (p<0.001). Smoking was less frequent in the K2-group (p=0.003). A previous infarction/revascularization history was similar in both groups. The infarction size, assessed by Troponin I/Creatin kinase, did not differ between groups (p=0.378 and p=0.855). Multivessel coronary disease and revascularization procedures were less common in group K2 (p=0.015 and p=0.005 vs group K1, respectively). Patients in K2 had a worse prognosis in terms of maximum Killip class, death and major adverse cardiovascular events (p<0.001). After multivariate analysis, mild HF at presentation was an independent risk factor for mortality (OR=6.50; IC 95%: 2.48-16.95; p<0.001). Conclusion: Mild HF at presentation in NSTEMI is linked to a poor prognosis, with increased short-term mortality. Thus, a more aggressive approach including early cardiac catheterization and revascularization should be considered., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Background: The prognosis of patients with left-sided endocarditis remains poor despite the progress of surgical techniques. Identification of high-risk patients within the first days after admission to the hospital would permit a more aggressive therapeutic approach. Methods: We designed a prospective multicenter study to find out the clinical, microbiologic, and echocardiographic characteristics available within 72 hours of admission that might define the profile of high-risk patients. Of 444 episodes, 317 left-sided endocarditis cases were included and 76 variables were assessed. Events were surgery in the active phase of the disease and in-hospital death. A stepwise logistic regression analysis was undertaken to determine variables predictive of events. Results: Multivariate analysis of the clinical variables found to have statistical significance in the univariate analysis identified the following as predictive: patient referred from another hospital (odds ratio [OR]: 1.8; confidence interval [CI], 1.1-2.9), atrioventricular block (OR: 2.5; CI, 1.1-5.9), acute onset (OR: 1.7; CI, 1.1-2.9), and heart failure at admission (OR: 2.3; CI, 1.4-3.8). When the echocardiographic and microbiological variables statistically significant in the univariate analysis were introduced, the presence of heart failure at admission (OR: 2.9; CI, 1.8-4.8), periannular complications (OR: 1.8; CI, 1.1-3.1), and Staphylococcus aureus infection (OR: 2.0; CI, 1.1-3.8) retained prognostic power. Risk could be accurately stratified when combining the 3 variables with predictive power: 0 variables present: 25% of risk; 1 variable present: 38% to 49% of risk; 2 variables present: 56% to 66% of risk; and 3 variables present: 79% of risk. Conclusions: The risk of patients with left-sided endocarditis can be accurately stratified with the assessment of variables easily available within 72 hours of admission to the hospital., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

Depto. de Fisiología, Fac. de Medicina, TRUE, pub

This review article describes in depth the current usefulness of transesophageal echocardiography in patients who undergo transcatheter aortic valve replacement. Pre-intervention, 3D-transesophageal echocardiography allows us to accurately evaluate the aortic valve morphology and to measure the valve annulus, helping us to choose the appropriate size of the prosthesis, especially useful in cases where the computed tomography is not of adequate quality. Although it is not currently used routinely during the intervention, it remains essential in those cases of greater complexity, such as for patients with greater calcification and bicuspid valve, mechanical mitral prosthesis, and “valve in valve” procedures. Three-dimensional transesophageal echocardiography is the best technique to detect and quantify paravalvular regurgitation, a fundamental aspect to decide whether immediate valve postdilation is needed. It also allows to detect early any immediate complications such as cardiac tamponade, aortic hematoma or dissection, migration of the prosthesis, malfunction of the prosthetic leaflets, or the appearance of segmental contractility disorders due to compromise of the coronary arteries ostium. Transesophageal echocardiography is also very useful in follow-up, to check the proper functioning of the prosthesis and to rule out complications such as thrombosis of the leaflets, endocarditis, or prosthetic degeneration., Depto. de Medicina, Fac. de Medicina, TRUE, pub, Descuento UCM

We have evaluated cardiac function and fibrosis in infarcted male Wistar rats treated with MitoQ (50 mg/kg/day) or vehicle for 4 weeks. A cohort of patients admitted with a first episode of acute MI were also analyzed with cardiac magnetic resonance and T1 mapping during admission and at a 12-month follow-up. Infarcted animals presented cardiac hypertrophy and a reduction in the left ventricular ejection fraction (LVEF) and E- and A-waves (E/A) ratio when compared to controls. Myocardial infarction (MI) rats also showed cardiac fibrosis and endoplasmic reticulum (ER) stress activation. Binding immunoglobulin protein (BiP) levels, a marker of ER stress, were correlated with collagen I levels. MitoQ reduced oxidative stress and prevented all these changes without affecting the infarct size. The LVEF and E/A ratio in patients with MI were 57.6 ± 7.9% and 0.96 ± 0.34, respectively. No major changes in cardiac function, extracellular volume fraction (ECV), or LV mass were observed at follow-up. Interestingly, the myeloperoxidase (MPO) levels were associated with the ECV in basal conditions. BiP staining and collagen content were also higher in cardiac samples from autopsies of patients who had suffered an MI than in those who had died from other causes. These results show the interactions between mitochondrial oxidative stress and ER stress, which can result in the development of diffuse fibrosis in the context of MI., Unión Europea, Instituto de Salud Carlos III, Depto. de Fisiología, Fac. de Medicina, TRUE, pub

La obesidad se define como una excesiva acumulación de grasa debido a undesequilibrio entre las calorías consumidas y gastadas. La obesidad mundial ha crecido dramáticamente en las últimas décadas por lo que no es sorprendente que numerosos estudios se hayan llevado a cabo para investigar su efecto dañino sobre la salud humana.Una de las características de los pacientes obesos es la presencia de adipocitos más grandes los cuáles una vez alcanzado su límite de expansión tienen una menor capacidad de almacenamiento de grasa dando lugar a un aumento de los niveles de ácidos grasos circulantes los cuales se pueden depositar en tejidos no adiposos, incluido el corazón, ejerciendo efectos tóxicos en los mismos. Además, la obesidad se asocia con alteraciones estructurales y funcionales en el corazón las cuales pueden dar lugar a disfunción cardiaca. De hecho, las enfermedades cardiovasculares son la primera causa de muerte en individuos con obesidad o diabetes. Entre los mecanismos que contribuyen a la aparición de alteraciones estructurales y funcionales se encuentran la lipotoxicidad cardiaca, las alteraciones en el uso de sustratos metabólicos, mediadores profibróticos como Galectina 3 (Gal-3), la disfunción mitocondrial y el estrés oxidativo, los cuales facilitan el desarrollo de fibrosis cardiaca con consecuencias funcionales. Niveles patológicos de especies reactivas de oxígeno siendo la mitocondria la principal fuente de los mismos, se ha demostrado que tienen un efecto dañino en el corazón..., Obesity is defined as an abnormal or excessive fat accumulation due to an energy imbalance between calories consumed and expended. Worldwide obesity has grown dramatically in the last decades so it is not surprising that numerous studies have been performed to investigate its harmful effect on human health. One of the characteristics of obese patients is the presence of larger adipocytes which reach a limit and have diminished capacity to store fat, thereby leading to elevation of circulating fatty acids which can deposit in non-adipose tissues, including the heart,exerting toxic effects. Moreover, obesity is associated with structural and functional alterations in the heart that can lead to cardiac dysfunction. In fact, cardiovascular disease is the primary cause of death in individuals with obesity and diabetes. Among the mechanisms that contribute to cardiac structural and functional alterations, cardiac lipotoxicity, alterations in the use of metabolic substrates, profibrotic mediators such as Galectin-3 (Gal-3), mitochondrial dysfunction and oxidative stress are some of these which facilitate the development of cardiac fibrosis with functional consequences. Pathological ROS levels have been demonstrated to have harmful effects in the heart, with the mitochondria being the main source of ROS. Moreover, oxidative stress can also participate in the adipose tissue remodelling which can be underlying metabolic alterations associated with obesity...

La obesidad se define como una excesiva acumulación de grasa debido a undesequilibrio entre las calorías consumidas y gastadas. La obesidad mundial ha crecido dramáticamente en las últimas décadas por lo que no es sorprendente que numerosos estudios se hayan llevado a cabo para investigar su efecto dañino sobre la salud humana.Una de las características de los pacientes obesos es la presencia de adipocitos más grandes los cuáles una vez alcanzado su límite de expansión tienen una menor capacidad de almacenamiento de grasa dando lugar a un aumento de los niveles de ácidos grasos circulantes los cuales se pueden depositar en tejidos no adiposos, incluido el corazón, ejerciendo efectos tóxicos en los mismos. Además, la obesidad se asocia con alteraciones estructurales y funcionales en el corazón las cuales pueden dar lugar a disfunción cardiaca. De hecho, las enfermedades cardiovasculares son la primera causa de muerte en individuos con obesidad o diabetes. Entre los mecanismos que contribuyen a la aparición de alteraciones estructurales y funcionales se encuentran la lipotoxicidad cardiaca, las alteraciones en el uso de sustratos metabólicos, mediadores profibróticos como Galectina 3 (Gal-3), la disfunción mitocondrial y el estrés oxidativo, los cuales facilitan el desarrollo de fibrosis cardiaca con consecuencias funcionales. Niveles patológicos de especies reactivas de oxígeno siendo la mitocondria la principal fuente de los mismos, se ha demostrado que tienen un efecto dañino en el corazón...

Objective We have studied the effect of moderate physical activity that is performed by healthy women during their entire pregnancy on their perception of health status. Study Design Eighty sedentary women were assigned randomly to either an exercise group (n = 40) or a control group (n = 40). Maternal perception of health status and several pregnancy outcomes were recorded. Results Significant differences (P = .03) were found between study groups in the percentage of women who perceived their health status as “very good”; the values that corresponded to the exercise group (n = 18; 54.5%) were better than those of the control group (n = 9; 27.3%). In addition, the women of the exercise group gained less weight (11,885 ± 3146 g) than those of the control group (13,903 ± 2113; P = .03). Conclusion A moderate physical activity program that is performed over the first, second, and third trimester of pregnancy improves the maternal perception of health status., Depto. de Fisiología, Fac. de Medicina, TRUE, pub

A pesar de todos los recientes avances diagnósticos y el amplio armamentario terapéutico, la endocarditis infecciosa sigue siendo una enfermedad grave que conlleva una elevada mortalidad intrahospitalaria. La vegetación es la lesión más característica de la enfermedad, y se considera un criterio diagnóstico. El ecocardiograma es la herramienta fundamental para su detección. Sin embargo, sigue existiendo controversia respecto a cuáles son los factores que determinan el tamaño de la vegetación. Es más, a pesar de ser una parte integral de la fisiopatología y diagnóstico de la enfermedad, la contribución del tamaño de la vegetación al pronóstico de la enfermedad sigue siendo objeto de debate. Se ha realizado un gran esfuerzo para identificar a los pacientes de alto riesgo que se podrían beneficiar de un tratamiento agresivas. Diferentes estudios han llegado a diferentes conclusiones, debido a la variabilidad en su metodología, a los criterios diagnósticos, al escaso número de pacientes incluidos, al carácter retrospectivo o prospectivo, y al uso del ecocardiograma transtorácico o transesofágico. Teniendo en cuenta las consideraciones anteriores, se ha llevado a cabo este estudio, basado en los hallazgos del primer ecocardiograma transesofágico en el episodio de endocarditis

Bases del tratamiento (La vegetación como foco infeccioso ; Medidas generales del tratamiento). Tratamiento antimicrobiano de la endocarditis infecciosa (Tratamiento empírico ; Tratamiento específico). Gérmenes poco frecuentes y de difícil identificación. Profilaxis de la endocarditis infecciosa (Lesiones cardiacas predisponentes ; Procedimientos que requieren profilaxis ; Regímenes antibióticos ; Otras consideraciones)