Renal dysfunction after orthotopic heart transplantation: incidence, natural history, and risk factors

[Abstract] Background. Renal dysfunction is a common complication after orthotopic heart transplantation (HT). The importance of factors other than exposure to immunosuppressive drugs is unclear. The purpose of this study was to determine the incidence and natural history of renal dysfunction following heart transplantation, and to evaluate a number of variables as risk factors for this condition. Methods. We examined the creatinine levels at 1, 6, 12, 24, and 60 months in 262 consecutive heart transplant patients who survived at least 1 year. The potential risk factors included pre- and posttransplantation diabetes mellitus, arterial hypertension, and drugs used to control arterial hypertension. Results. 17.2% of patients showed mild renal dysfunction (creatinine 1.5-2.5 mg/dL) and 1.9% moderate dysfunction (creatinine >2.5 mg/dL) at 1 month; 29.8% showed mild and 1.1% moderate dysfunction at 6 months; 33.2% showed mild and 1.9% moderate dysfunction at 1 year; 40% showed mild, 0.9% moderate and 0.4% severe dysfunction (requiring dialysis or renal transplantation) at 2 years; and 43.6% showed mild, 1.7% moderate and 0.9% severe dysfunction at 5 years. None of the conditions analyzed as possible risk factors showed a significant association with renal dysfunction except the use of diuretics. Conclusion. The incidence of renal dysfunction after orthotopic heart transplantation was 33.6% within the first year after transplant and 44% within the first five years, although more than 95% of cases were mild. The incidence increased with time after transplantation. Renal dysfunction seems likely to be multifactorial in origin, but no individual risk factors were identified

Perfiles analíticos pre-configurados en insuficiencia cardiaca: implementación y uso en el Sistema Nacional de Salud Español

Objetivos: El uso de los perfiles analíticos pre-configurados (PAPs) en el contexto de la insuficiencia cardíaca (IC) podría ayudar a realizar un mejor manejo clínico y gestión eficiente del paciente. Los objetivos del estudio son entender el grado actual de implantación de los PAPs en el manejo de la IC en España y conocer la opinión de expertos sobre los mismos, prestando particular atención a los parámetros del metabolismo del hierro. Métodos: Se recopiló la opinión de expertos en IC en tres fases. FASE 1: nivel de implantación de los PAPs (n=40). FASE 2: ventajas y desventajas de su uso (n=12). FASE 3: grado de conformidad con la composición de tres PAPs específicos de IC (perfil de evaluación inicial, perfil de seguimiento y perfil de novo; n=16). Resultados: Un 62, 5% de los hospitales hacen uso de PAPs para el manejo clínico de la IC, sin encontrarse asociación con su nivel de referencia (p=0, 132), localización (p=0, 486) o presencia de Unidad de Insuficiencia Cardíaca (p=0, 737). Los expertos opinaron que emplear los PAPs en la práctica clínica presenta más ventajas que inconvenientes (8 vs. 3), resaltando los beneficios sobre el diagnóstico. Se identificaron un total de 3 motivaciones y 3 barreras para la implantación de los PAPs. Los expertos valoraron positivamente la composición de los 3 PAPs de IC propuestos. Conclusiones: La estandarización y homogenización de las pruebas de diagnóstico y seguimiento en los pacientes con IC es un área de mejora en los hospitales españoles analizados, a pesar de que los expertos consultados se han mostrado partidarios de su utilización

Registro Español de Trasplante Cardiaco. XXVI Informe Oficial de la Sección de Insuficiencia Cardiaca y Trasplante Cardiaco de la Sociedad Española de Cardiología (1984-2014)

[Resumen] Introducción y objetivos. Se presentan las características y resultados del trasplante cardiaco en España desde que empezó su actividad en mayo de 1984. Métodos. Se realiza un análisis descriptivo de las características de los receptores, los donantes, el procedimiento quirúrgico y los resultados de los trasplantes cardiacos realizados en España hasta el 31 de diciembre de 2014. Resultados. Durante 2014 se han realizado 266 procedimientos, con lo que la serie histórica consta de 7.289 trasplantes. El análisis temporal confirma un empeoramiento significativo del perfil clínico de los receptores (mayor porcentaje de pacientes añosos, con insuficiencia renal grave, diabetes insulinodependiente, cirugía cardiaca previa y ventilación mecánica), de los donantes (mayor porcentaje de donantes añosos y con mayor discordancia de peso) y del procedimiento (mayor porcentaje de trasplante urgente, que en 2014 alcanza el 41,4%, y con tiempo de isquemia > 240 min). El uso de dispositivos de asistencia mecánica ha disminuido respecto a 2013, y en 2014 supone el 18,8% del total de pacientes. La supervivencia a 1, 5, 10 y 15 años es del 76, el 65, el 52 y el 38% respectivamente, y permanece estable desde 1995. Conclusiones. La actividad de trasplante cardiaco en España permanece estable en los últimos años, con alrededor de 250 procedimientos al año. A pesar del claro empeoramiento de las características de donantes, receptores y tiempos quirúrgicos, se mantienen unos resultados en mortalidad comparables a los del entorno y se confirma un uso creciente de los dispositivos de asistencia circulatoria antes del trasplante

Hypotension, acidosis and vasodilation syndrome after heart transplant: incidence, risk factors, and prognosis

[Abstract] Background. HAV syndrome, the combination of hypotension, acidosis and vasodilation (HAV), is a serious postoperative complication after heart transplantation (HT). Its etiology and prognosis are poorly understood. Aim. To determine the incidence and prognosis of post-HT HAV syndrome and examine possible risk factors. Methods. Retrospective examination of the records of 85 consecutive patients who underwent HT between December 1999 and June 2002 sought the HAV criteria: systolic BP <85 mm Hg plus HCO3 <19 mEq/l whole excluding cardiogenic, hypovolemic and septic shock. Donor variables included sex, age, weight, height, cause of death, time in ICU, and ischemic time; while recipient variables, sex, age, weight, height, etiology of cardiopathy, previous cardiopulmonary bypass surgery, preoperative amiodarone, β-blockers, catecholamines, mechanical ventilation or intra aortic balloon pump (IABP), RVP, time on waiting list, pump time, reoperations, polytransfusion, preoperative creatinine, GOT, GPT and GGT, induction with OKT3 or anti-CD25, bypass-to-HAV time, duration of catecholamine treatment, and 1 month survival after HT. Results. The 11 HAV cases (13%) appeared between 1 and 72 h after HT (75% in the first hour). Catecholamines were used for 1 to 6 days; control was achieved within 48 h in 58% of cases. Two HAV patients (18%) died within the first month versus six non-HAV patients (8.1%) (P = .275). Only polytransfusion showed more than a borderline value to predict HAV syndrome. Conclusions. HAV syndrome has an incidence of 13% and a mortality of 18% within 1 month post-HT. The only likely risk factor is polytransfusion

Registro Español de Trasplante Cardiaco. XXVII Informe Oficial de la Sección de Insuficiencia Cardiaca y Trasplante Cardiaco de la Sociedad Española de Cardiología (1984-2015)

[Abstract] Introduction and objectives. The present article reports the characteristics and results of heart transplants in Spain since this therapeutic modality was first used in May 1984. Methods. We describe the main features of recipients, donors, surgical procedures, and results of all heart transplants performed in Spain until December 31, 2015. Results. A total of 299 cardiac transplants were performed in 2015, with the whole series comprising 7588 procedures. The main transplant features in 2015 were similar to those observed in recent years. A remarkably high percentage of transplants were performed under emergency conditions and there was widespread use of circulatory assist devices, particularly continuous-flow left ventricular assist devices prior to transplant (16% of all transplants). Survival has significantly improved in the last decade compared with previous time periods. Conclusions. During the last few years, between 250 and 300 heart transplants have consistently been performed each year in Spain. Despite a more complex clinical context, survival has increased in recent years.[Resumen] Introducción y objetivos. Se presentan las características y los resultados del trasplante cardiaco en España desde que empezó su actividad en mayo de 1984. Métodos. Se realiza un análisis descriptivo de las características de los receptores, los donantes, los procedimientos quirúrgicos y los resultados de los trasplantes cardiacos realizados en España hasta el 31 de diciembre de 2015. Resultados. Durante 2015 se han realizado 299 procedimientos, con lo que la serie histórica consta de 7.588 trasplantes. Las características generales del procedimiento son similares a las observadas en los últimos años y destacan el alto porcentaje de procedimientos realizados en código urgente y, sobre todo, la extensión del uso de dispositivos de asistencia circulatoria, particularmente la asistencia ventricular de flujo continuo (el 16% del total de trasplantes). La supervivencia ha aumentado significativamente en la última década con respecto a periodos anteriores. Conclusiones. La actividad de trasplante cardiaco en España permanece estable en los últimos años, con alrededor de 250-300 procedimientos al año. A pesar de la mayor complejidad del contexto clínico, se observa una mejora de la supervivencia en los últimos años

Clinical Characteristics and Long-term outcomes of patients undergoing combined heart-kidney transplantation: a single-center experience

[Abstract] Background. The purpose of the study was to describe clinical characteristics and long-term survival of patients undergoing combined heart-kidney transplant in a single center. Methods. We conducted a retrospective analysis of 22 consecutive patients who underwent combined heart-kidney transplant at our institution between 1995 and 2013. Long-term outcomes were analyzed by means of the Kaplan-Meier method. Results. Four patients underwent re-do transplant (2 cardiac re-transplants, 1 kidney re-transplant, and 1 combined heart-kidney re-transplant). Most frequent underlying cardiac conditions were coronary artery disease (54%), dilated cardiomyopathy (23%), and chronic rejection of a previous heart graft (18%). Known causes of chronic renal dysfunction were nephroangioesclerosis (23%), drug-related toxicity (14%), and Wegener granulomatosis (5%). Non-specified chronic renal dysfunction was present in 50% patients. In-hospital postoperative mortality rate was 5 of 22 (23%). Causes of early death were directly related to kidney transplant surgery in 4 of 5 (80%) patients. Among the remaining 17 patients who surmounted the postoperative period, long-term survival rates 1 year, 5 years, and 10 years after HKT were 88%, 82%, and 65%, respectively. Over a mean follow-up of 6.7 ± 6.4 years, cumulative incidences of cytomegalovirus infection, coronary allograft vasculopathy, malignancy, and acute cardiac graft rejection were 41%, 6%, 24%, and 41%, respectively. There was no episode of acute renal graft rejection. At the end of follow-up, all survivors (n = 11) were in functional New York Heart Association class I. Mean creatinine serum level was 1.68 mg/dL. Conclusions. In our experience, combined heart-kidney transplant is a feasible therapeutic option that yielded favorable long-term outcomes, with a low cumulative incidence of cardiac graft dysfunction. These results were obtained at the expense of a significant risk of early postoperative mortality, which was mainly related to complications of kidney transplant surgery

Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure: the LION-HEART multicentre randomised trial

Aims: The LION-HEART study was a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial evaluating the efficacy and safety of intravenous administration of intermittent doses of levosimendan in outpatients with advanced chronic heart failure. Methods and results: Sixty-nine patients from 12 centres were randomly assigned at a 2: 1 ratio to levosimendan or placebo groups, receiving treatment by a 6-hour intravenous infusion (0.2 mu g/kg/min without bolus) every 2weeks for 12weeks. The primary endpoint was the effect on serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) throughout the treatment period in comparison with placebo. Secondary endpoints included evaluation of safety, clinical events and health-related quality of life (HRQoL). The area under the curve (AUC, pg.day/mL) of the levels of NT-proBNP over time for patients who received levosimendan was significantly lower than for the placebo group {344 x 10(3) [95% confidence interval (CI) 283 x 10(3)-404 x 10(3)] vs. 535 x 10(3) [443 x 10(3)-626 x 10(3)], P = 0.003}. In comparison with the placebo group, the patients on levosimendan experienced a reduction in the rate of heart failure hospitalisation (hazard ratio 0.25; 95% CI 0.11-0.56; P = 0.001). Patients on levosimendan were less likely to experience a clinically significant decline in HRQoL over time (P = 0.022). Adverse event rates were similar in the two treatment groups. Conclusions: In this small pilot study, intermittent administration of levosimendan to ambulatory patients with advanced systolic heart failure reduced plasma concentrations of NT-proBNP, worsening of HRQoL and hospitalisation for heart failure. The efficacy and safety of this intervention should be confirmed in larger trials

Specialized pro-resolving mediators prevents cardiac dysfunction by modulating Ca2+ handling and NRF2 axis

Trabajo presentado en el ESC Congress 2021 - The Digital Experience, celebrado en modalidad virtual el 27 de agosto de 2021

Long‐term safety of intravenous cardiovascular agents in acute heart failure: results from the European Society of Cardiology Heart Failure Long‐Term Registry

[Abstract] Aims. The aim of this study was to assess long‐term safety of intravenous cardiovascular agents—vasodilators, inotropes and/or vasopressors—in acute heart failure (AHF). Methods and results. The European Society of Cardiology Heart Failure Long‐Term (ESC‐HF‐LT) registry was a prospective, observational registry conducted in 21 countries. Patients with unscheduled hospitalizations for AHF (n = 6926) were included: 1304 (18.8%) patients received a combination of intravenous (i.v.) vasodilators and diuretics, 833 (12%) patients received i.v. inotropes and/or vasopressors. Primary endpoint was long‐term all‐cause mortality. Main secondary endpoints were in‐hospital and post‐discharge mortality. Adjusted hazard ratio (HR) showed no association between the use of i.v. vasodilator and diuretic and long‐term mortality [HR 0.784, 95% confidence interval (CI) 0.596–1.032] nor in‐hospital mortality (HR 1.049, 95% CI 0.592–1.857) in the matched cohort (n = 976 paired patients). By contrast, adjusted HR demonstrated a detrimental association between the use of i.v. inotrope and/or vasopressor and long‐term all‐cause mortality (HR 1.434, 95% CI 1.128–1.823), as well as in‐hospital mortality (HR 1.873, 95% CI 1.151–3.048) in the matched cohort (n = 606 paired patients). No association was found between the use of i.v. inotropes and/or vasopressors and long‐term mortality in patients discharged alive (HR 1.078, 95% CI 0.769–1.512). A detrimental association with inotropes and/or vasopressors was seen in all geographic regions and, among catecholamines, dopamine was associated with the highest risk of death (HR 1.628, 95% CI 1.031–2.572 vs. no inotropes). Conclusions. Vasodilators did not demonstrate any association with long‐term clinical outcomes, while inotropes and/or vasopressors were associated with increased risk of all‐cause death, mostly related to excess of in‐hospital mortality in AHF