Pro-BNP como marcador de riesgo en cirugía cardiaca

INTRODUCCIÓN: El riesgo quirúrgico en cirugía cardiaca es valorado mediante formularios que calculan una probabilidad estimada de mortalidad peroperatoria en función de las características del paciente y de la cirugía. De todos ellos, el más utilizado en cirugía cardiaca es el sistema Euroscore. Sin embargo, la gran mayoría de los parámetros incluidos son factores clínicos no modificables. No hay consensuados en la actualidad parámetros bioquímicos que puedan predecir e identificar pacientes con un riesgo más elevado. El péptido natriurético cerebral o BNP es una hormona cardiovascular, cuya determinación actúa como predictor de riesgo y factor pronóstico demostrado en insuficiencia cardiaca y representaría de este modo, una variable más objetiva para valoración del riesgo en el caso de los pacientes sometidos a una cirugía cardiaca. HIPÓTESIS: Los valores de pro-BNP pre y postoperatorios servirán de marcador de riesgo en cirugía cardiaca. MATERIAL Y MÉTODOS: para la realización de nuestro estudio se ha tomado una muestra de 135 pacientes consecutivos, intervenidos de cirugía cardiaca con circulación extracorpórea en el servicio de Cirugía Cardiovascular del Hospital Universitario Miguel Servet de Zaragoza entre 2012 y 2013, con un seguimiento a 18 meses. Se realizó una determinación preoperatoria y otra a las 24 horas tras la IQ de los valores de pro-BNP. Los datos han sido analizados y procesados estadísticamente mediante hoja de cálculo y programa estadístico con el que se han realizado test de contraste de hipótesis y regresión logística. RESULTADOS: las condiciones basales del estudio fueros similares a las encontradas a la literatura en cuanto a edad, sexo y factores de riesgo cardiovasculares. La media de Euroscore II fue de 2,49 (riesgo moderado). la insuficiencia cardiaca se encontró en un 10 % mientras que la insuficiencia renal tuvo una incidencia del 22% de pacientes de la muestra. La mortalidad perioperatoria fue de 5 pacientes (4%). No se encontraron diferencias significativas entre los valores de pro-BNP preoperatorio con Euroscore II, cifras de troponinas, tiempo de clampaje, estancia hospitalaria, complicaciones respiratorias y complicaciones infecciosas. Se encontraron diferencias significativas entre los valores de pro-BNP preoperatorio y postoperatorio en los casos de insuficiencia cardiaca y renal. CONCLUSIONES: en la mayor parte de los pacientes la cirugía cardiaca induce un aumento, muy variable, de los valores postoperatorios de pro-BNP respecto a los preoperatorios. Valores elevados de pro-BNP preoperatorios se correlacionan con una mayor incidencia de disfunción cardiaca e insuficiencia renal postoperatorias, no siendo esta elevación específica. No se ha podido establecer una escala de riesgo de los valores de pro-BNP postoperatorios para predecir el riesgo de morbimortalidad postcirugía cardiaca. Pro-BNP tiene un comportamiento distinto según el tipo de cirugía

Ruptura del músculo papilar anterolateral, una causa poco común de complicación post isquémica: reporte de caso

Despite the low incidence of mechanical complications in myocardial infarction, the severity of them requires a fast and accurate diagnosis, as well as early treatment, with echocardiography being the leading imaging technique in these cases. Classically, the most frequently affected papillary muscle is the posteromedial one, due to its unique vascularization by the posterior descending artery. We present the case of a patient with rupture of the anterolateral muscle and secondary acute mitral insufficiency as a complication of a previous infarction due to occlusion of the anterior descending artery.A pesar de la baja incidencia de las complicaciones mecánicas del infarto de miocardio, la gravedad que implican exige un rápido y acertado diagnóstico, así como un tratamiento precoz, siendo la ecocardiografía la técnica de imagen protagonista en estos casos. Clásicamente, el músculo papilar más frecuentemente afectado es el posteromedial, por su vascularización única por la arteria descendente posterior. Presentamos el caso de un paciente con ruptura del músculo anterolateral e insuficiencia mitral aguda secundaria como complicación de un infarto anterior evolucionado por oclusión de la arteria descendente anterior

Automatic quantification of cardiomyocyte dimensions and connexin 43 lateralization in fluorescence images

Cardiomyocytes’ geometry and connexin 43 (CX43) amount and distribution are structural features that play a pivotal role in electrical conduction. Their quantitative assessment is of high interest in the study of arrhythmias, but it is usually hampered by the lack of automatic tools. In this work, we propose a software algorithm (Myocyte Automatic Retrieval and Tissue Analyzer, MARTA) to automatically detect myocytes from fluorescent microscopy images of cardiac tissue, measure their morphological features and evaluate the expression of CX43 and its degree of lateralization. The proposed software is based on the generation of cell masks, contouring of individual cells, enclosing of cells in minimum area rectangles and splitting of these rectangles into end-to-end and middle compartments to estimate CX43 lateral-to-total ratio. Application to human ventricular tissue images shows that mean differences between automatic and manual methods in terms of cardiomyocyte length and width are below 4 µm. The percentage of lateral CX43 also agrees between automatic and manual evaluation, with the interquartile range approximately covering from 3% to 30% in both cases. MARTA is not limited by fiber orientation and has an optimized speed by using contour filtering, which makes it run hundreds of times faster than a trained expert. Developed for CX43 studies in the left ventricle, MARTA is a flexible tool applicable to morphometric and lateralization studies of other markers in any heart chamber or even skeletal muscle. This open-access software is available online.Fil: Oliver Gelabert, Antoni. Universidad de Zaragoza; EspañaFil: García Mendívil, Laura. Universidad de Zaragoza; EspañaFil: Vallejo Gil, José María. University Hospital Miguel Servet; EspañaFil: Fresneda Roldán, Pedro Carlos. University Hospital Miguel Servet; EspañaFil: Andelová, Katarína. Centre of Experimental Medicine; EslovaquiaFil: Fañanás Mastral, Javier. University Hospital Miguel Servet; EspañaFil: Vázquez Sancho, Manuel. University Hospital Miguel Servet; EspañaFil: Matamala Adell, Marta. University Hospital Miguel Servet; EspañaFil: Sorribas Berjón, Fernando. University Hospital Miguel Servet; EspañaFil: Ballester Cuenca, Carlos. University Hospital Miguel Servet; EspañaFil: Tribulova, Narcisa. Centre of Experimental Medicine; EslovaquiaFil: Ordovás, Laura. Universidad de Zaragoza; EspañaFil: Diez, Emiliano Raúl. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; ArgentinaFil: Pueyo, Esther. Biomedical Research Networking Center in Bioengineering; España. Universidad de Zaragoza; Españ

Minimally invasive system to reliably characterize ventricular electrophysiology from living donors

Cardiac tissue slices preserve the heterogeneous structure and multicellularity of the myocardium and allow its functional characterization. However, access to human ventricular samples is scarce. We aim to demonstrate that slices from small transmural core biopsies collected from living donors during routine cardiac surgery preserve structural and functional properties of larger myocardial specimens, allowing accurate electrophysiological characterization. In pigs, we compared left ventricular transmural core biopsies with transmural tissue blocks from the same ventricular region. In humans, we analyzed transmural biopsies and papillary muscles from living donors. All tissues were vibratomesliced. By histological analysis of the transmural biopsies, we showed that tissue architecture and cellular organization were preserved. Enzymatic and vital staining methods verifed viability. Optically mapped transmembrane potentials confrmed that action potential duration and morphology were similar in pig biopsies and tissue blocks. Action potential morphology and duration in human biopsies and papillary muscles agreed with published ranges. In both pigs and humans, responses to increasing pacing frequencies and β-adrenergic stimulation were similar in transmural biopsies and larger tissues. We show that it is possible to successfully collect and characterize tissue slices from human myocardial biopsies routinely extracted from living donors, whose behavior mimics that of larger myocardial preparations both structurally and electrophysiologically.Fil: Oliván Viguera, Aida. Universidad de Zaragoza; EspañaFil: Pérez Zabalza, María. Universidad de Zaragoza; EspañaFil: García Mendívil, Laura. Universidad de Zaragoza; EspañaFil: Mountris, Konstantinos A.. Universidad de Zaragoza; EspañaFil: Orós Rodrigo, Sofía. Universidad de Zaragoza; EspañaFil: Ramos Marquès, Estel. Universidad de Zaragoza; EspañaFil: Vallejo Gil, José María. University Hospital Miguel Servet; EspañaFil: Fresneda Roldán, Pedro Carlos. University Hospital Miguel Servet; EspañaFil: Fañanás Mastral, Javier. University Hospital Miguel Servet; EspañaFil: Vázquez Sancho, Manuel. University Hospital Miguel Servet; EspañaFil: Matamala Adell, Marta. University Hospital Miguel Servet; EspañaFil: Sorribas Berjón, Fernando. University Hospital Miguel Servet; EspañaFil: Bellido Morales, Javier André. University Hospital Miguel Servet; EspañaFil: Mancebón Sierra, Francisco Javier. University Hospital Miguel Servet; EspañaFil: Vaca Núñez, Alexánder Sebastián. University Hospital Miguel Servet; EspañaFil: Ballester Cuenca, Carlos. University Hospital Miguel Servet; EspañaFil: Marigil, Miguel Ángel. Hospital San Jorge; EspañaFil: Pastor, Cristina. Aragón Institute of Health Sciences; EspañaFil: Ordovás, Laura. Aragón Agency for Research and Development; España. Universidad de Zaragoza; EspañaFil: Köhler, Ralf. Aragón Institute of Health Sciences; España. Aragón Agency for Research and Development; EspañaFil: Diez, Emiliano Raúl. Universidad Nacional de Cuyo. Facultad de Ciencias Médicas. Cátedra de Fisiología Humana Normal; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; ArgentinaFil: Pueyo, Esther. Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina; España. Universidad de Zaragoza; Españ

Chronological and biological aging of the human left ventricular myocardium: Analysis of microRNAs contribution

Aging is the main risk factor for cardiovascular diseases. In humans, cardiac aging remains poorly characterized. Most studies are based on chronological age (CA) and disregard biological age (BA), the actual physiological age (result of the aging rate on the organ structure and function), thus yielding potentially imperfect outcomes. Deciphering the molecular basis of ventricular aging, especially by BA, could lead to major progresses in cardiac research. We aim to describe the transcriptome dynamics of the aging left ventricle (LV) in humans according to both CA and BA and characterize the contribution of microRNAs, key transcriptional regulators. BA is measured using two CA-associated transcriptional markers: CDKN2A expression, a cell senescence marker, and apparent age (AppAge), a highly complex transcriptional index. Bioinformatics analysis of 132 LV samples shows that CDKN2A expression and AppAge represent transcriptomic changes better than CA. Both BA markers are biologically validated in relation to an aging phenotype associated with heart dysfunction, the amount of cardiac fibrosis. BA-based analyses uncover depleted cardiac-specific processes, among other relevant functions, that are undetected by CA. Twenty BA-related microRNAs are identified, and two of them highly heart-enriched that are present in plasma. We describe a microRNA-gene regulatory network related to cardiac processes that are partially validated in vitro and in LV samples from living donors. We prove the higher sensitivity of BA over CA to explain transcriptomic changes in the aging myocardium and report novel molecular insights into human LV biological aging. Our results can find application in future therapeutic and biomarker research

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Disección de arterias coronarias: ¿y ahora qué hago?

Objetivo: La disección de arterias coronarias es una entidad con escasa frecuencia. Su espectro clínico puede abarcar desde la muerte súbita, el infarto agudo de miocardio o la angina de pecho. No hay un consenso acerca de la mejor opción terapéutica. Métodos: Se analizan 4 casos acontecidos en los últimos años. Un varón de 56 años y una mujer de 50 años en los que se realiza cirugía de revascularización miocárdica, una mujer de 46 años en la que se implanta un stent, y una mujer de 48 años en la que se decide tratamiento médico. Resultados: Dichos pacientes presentaron una evolución favorable pudiendo ser dados de alta. En seguimiento, los pacientes sometidos a cirugía no han presentado otros eventos de interés, permaneciendo estables. En el caso de la paciente sobre la que se realizó intervencionismo presentó redisección con implante de nuevo stent a los 3 años. El último caso ha permanecido estable y ha sido dado de alta recientemente. Conclusiones: La conducta a seguir es variada sin existir consenso ni estandarización. Si el paciente está estable y el vaso es pequeño puede considerarse tratamiento médico. Si el paciente está inestable hay una mayor indicación de intervencionismo. En los casos de disección del tronco coronario izquierdo y multivaso la tendencia es hacia la cirugía de bypass coronaria. Dada la escasa incidencia de la enfermedad sería interesante el estudio de series mayores de casos para la confrontación de resultados y poder determinar de una manera más eficaz el mejor tratamiento a seguir

Chronological and biological aging of the human left ventricular myocardium: Analysis of microRNAs contribution

Aging is the main risk factor for cardiovascular diseases. In humans, cardiac aging remains poorly characterized. Most studies are based on chronological age (CA) and disregard biological age (BA), the actual physiological age (result of the aging rate on the organ structure and function), thus yielding potentially imperfect outcomes. Deciphering the molecular basis of ventricular aging, especially by BA, could lead to major progresses in cardiac research. We aim to describe the transcriptome dynamics of the aging left ventricle (LV) in humans according to both CA and BA and characterize the contribution of microRNAs, key transcriptional regulators. BA is measured using two CA-associated transcriptional markers: CDKN2A expression, a cell senescence marker, and apparent age (AppAge), a highly complex transcriptional index. Bioinformatics analysis of 132 LV samples shows that CDKN2A expression and AppAge represent transcriptomic changes better than CA. Both BA markers are biologically validated in relation to an aging phenotype associated with heart dysfunction, the amount of cardiac fibrosis. BA-based analyses uncover depleted cardiac-specific processes, among other relevant functions, that are undetected by CA. Twenty BA-related microRNAs are identified, and two of them highly heart-enriched that are present in plasma. We describe a microRNA-gene regulatory network related to cardiac processes that are partially validated in vitro and in LV samples from living donors. We prove the higher sensitivity of BA over CA to explain transcriptomic changes in the aging myocardium and report novel molecular insights into human LV biological aging. Our results can find application in future therapeutic and biomarker research