Valoración global del corazón en el paciente con transplante cardiaco mediante tomografía computarizada de doble fuente

In routine clinical practice surveillance of heart transplant recipients is usually performed using echocardiography and conventional coronary angiography. The latter permits diagnosis and follow-up of coronary allograft vasculopathy. However, this procedure is invasive and is not free of complications. Conventional multislice computed tomography (MSCT) has been shown to be a useful non-invasive tool for ruling out coronary artery disease and evaluating cardiac function. However, due to its limited temporal resolution betablocker administration is required, and its usefulness in certain patient populations with restricted response to this medication, such as heart transplant recipients, may therefore be limited. Dual-source CT (DSCT) allows evaluation of the coronary arteries in all individuals independent of their heart rate. In the case presented here, we demonstrate that DSCT may be useful for evaluating cardiac function and ruling out coronary allograft vasculopathy in heart transplant recipients

Dual-source CT for visualization of the coronary arteries in heart transplant patients with high heart rates

OBJECTIVE. The purpose of this study was to evaluate the quality of dual-source CT images of the coronary arteries in heart transplant recipients with high heart rates. SUBJECTS AND METHODS. Contrast-enhanced dual-source CT coronary angiography was performed on 23 heart transplant recipients (20 men, three women; mean age, 61.1 ± 12.8 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent readers using a 5-point scale (0, not evaluative; 4, excellent quality) assessed the quality of images of coronary segments. RESULTS. The mean heart rate during scanning was 89.2 ± 10.4 beats/min. Interobserver agreement on the quality of images of the whole coronary tree was a kappa value of 0.78 and for selection of the optimal reconstruction interval was a kappa value of 0.82. The optimal reconstruction interval was systole in 17 (74%) of the 23 of heart transplant recipients. At the best reconstruction interval, diagnostic image quality (score ≥ 2) was obtained in 92.1% (303 of 329) of the coronary artery segments. The mean image quality score for the whole coronary tree was 3.1 ± 1.01. No significant correlation between mean heart rate (ρ = 0.31) or heart rate variability (ρ = 0.23) and overall image quality score was observed (p = not significant). CONCLUSION. Dual-source CT acquisition yields coronary angiograms of diagnostic quality in heart transplant recipients. Mean heart rate and heart rate variability during scanning do not have a negative effect on the overall quality of images of the coronary arteries

Trasplante de homoinjertos valvulares cardiacos y vasculares

The advances in the manipulation of human tissues, the development of cryobiology, paediatric cardiac surgery, the impossibility of obtaining an ideal prosthetic cardiac valve and the surgical treatment of cardiovascular infections have revived interest in the use of homografts. The donors of these homografts can be: a) Live donors: aortic and pulmonary valve of the recipient of a heart transplant; b) Multiorgan donors with a diagnosis of death according to neurological criteria, whose heart is rejected for heart transplant; c) Cadaver donors with asystolia of less than 8 hours. Homograft cardiac valves are the substitute of choice in aortic valve endocarditis, patients with counter-indications for anticoagulation, reconstruction of the outflow tract of the right ventricle, aortic valve replacement in children and young adults through the Ross operation, and an optional indication is the aortic valve and/or rising aorta replacement in patients over 60 years of age. Although there are not sufficiently broad series of homogratfs with arterial substitutes, with respect to the number of patients and time of evolution, the results suggest that this can benefit patients with vascular infection, immunodepressed patients or complex patients whose technique during the operation might require a homograft

Surgical treatment of aortobronchial fistula after thoracic endograft failure

Endovascular stent grafting has been recently considered as a less invasive alternative to either medical therapy or open surgical treatment for many patients with descending thoracic aortic disease. Late complications are rarely described in literature. Herein, we described the occurrence of an aorto-bronchial fistula and a retro-A dissection in a 73-year-old man after stent-grafting for a penetrating atherosclerotic ulcer (PAU) of the descending thoracic aorta and the successful surgical technique adopted in order to remove the stent-graft

Trasplante cardíaco

A heart transplant is at present considered the treatment of choice in cases of terminal cardiac insufficiency refractory to medical or surgical treatment. Due to factors such as the greater life expectancy of the population and the more efficient management of acute coronary syndromes, there is an increasing number of people who suffer from heart failure. It is estimated that the prevalence of the disease in developed countries is around 1%; of this figure, some 10% are in an advanced stage and are thus potential receptors of a heart transplant. The problem is that it is still not possible to offer this therapeutic form to all of the patients that require it. Consequently, it is necessary to optimise the results of the heart transplant through the selection of patients, selection and management of donors, perioperative management and control of the disease due to graft rejection. Since the first transplant carried out in 1967, numerous advances and changes have taken place, which has made it possible to increase survival and quality of life of those who have received a new heart. In this article we review the most relevant aspects of the heart transplant and the challenges that are currently faced

[Extracorporeal circulation in no-cardiac surgery: experience at the Clinica Universidad de Navarra].

Analyse the use of the Extra-Corporeal Circulation (ECC) in no-cardiac operations at the Clinica Universidad de Navarra. Between 1985 and 2009, the ECC has been involved in 28 operations for retroperitoneal tumour with inferior vena cava thrombus, in 43 isolated hyperthermic perfusion of a limb for locally advanced cancer and in 8 cases of chest mass with invasion of the pulmonary veins or bronchial carina. The intraoperative mortality for renal cancer has been of 7% while the 28% of patients showed a major complication. None patient died for the isolated hyperthermic perfusion and the 81% showed no toxicity. 1 patient out of 8 for chest mass died during the surgery for impossibility of weaning from the ECC. The ECC has been utilised in our experience mostly in cases of advanced cancer. It is an aggressive technique with a certain rate of complications. Nevertheless mid- and long-term results are encouraging. The ECC is the only technique in some advanced cancer in order to safely perform the mass removal. The precise co-ordination of the team is necessary to reduce the complication rate

Impact on renal function of the use of sirolimus in cardiac transplantation.

During the last few years sirolimus has been introduced as an alternative to preserve renal function in transplant recipients receiving calcineurin inhibitors. We reviewed our results on the use of sirolimus in cardiac transplant recipients. Twenty-seven patients with an average age of 63 years received sirolimus. The average time after transplantation was 73.4 +/- 58.9 months and the average follow-up was 31.7 +/- 18.01 months. Sirolimus was prescribed in 37% of cases due to chronic renal failure (CRF), 14.8% because of cardiac allograft vasculopathy (CAV), 11.1% for tumors, 22.2% de novo, 7.4% for CRF and tumor, and 7.4% for CRF and CAV. Among the patients with CRF (n = 14), there were 5 (35%) on dialysis at the moment of starting the treatment and 1 was retired from dialysis. The other 4 (28.5%) patients had to be treated with dialysis after starting the treatment. In all, 42.8% of the patients with nephropathy maintained stable renal function or improved. Among the 17 (63%) patients who did not require dialysis, there was no significant change in renal function after 6 months or 1, 2, and 3 years follow-up. The use of sirolimus in cardiac transplantation maintains stable renal function in the majority of patients in the medium term

Cianosis después del cierre quirúrgico de una comunicación interauricular

El cierre en el momento oportuno de las comunicaciones interauriculares (CIA) del tipo defecto de fosa oval, ostium secundum en la nomenclatura anglosajona, garantiza una vida normal y el riesgo quirúrgico tiende a cero. Pero existe una variedad de estas malformaciones congénitas que induce a errores quirúrgicos que, aunque raros, se siguen repitiendo desde el inicio de la cirugía cardíaca. Se trata de las CIA con limbo incompleto situadas en la parte inferior del septo, que se extienden hasta la desembocadura de la vena cava inferior y coinciden con una válvula de Eustaquio grande. En estos casos se puede producir una desviación inadvertida de la vena cava inferior hacia la aurícula izquierda al suturar erróneamente los bordes del limbo a la válvula de Eustaquio. Informamos de un niño de 7 años, operado 2 años antes de una CIA, que presentaba cianosis y disnea de esfuerzo, y del tratamiento quirúrgico seguido para su corrección. Para prevenir esta complicación es importante prestar atención a la anatomía y comenzar el cierre de las CIA por su extremo inferior

Dual-source CT for visualization of the coronary arteries in heart transplant patients with high heart rates

OBJECTIVE. The purpose of this study was to evaluate the quality of dual-source CT images of the coronary arteries in heart transplant recipients with high heart rates. SUBJECTS AND METHODS. Contrast-enhanced dual-source CT coronary angiography was performed on 23 heart transplant recipients (20 men, three women; mean age, 61.1 ± 12.8 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent readers using a 5-point scale (0, not evaluative; 4, excellent quality) assessed the quality of images of coronary segments. RESULTS. The mean heart rate during scanning was 89.2 ± 10.4 beats/min. Interobserver agreement on the quality of images of the whole coronary tree was a kappa value of 0.78 and for selection of the optimal reconstruction interval was a kappa value of 0.82. The optimal reconstruction interval was systole in 17 (74%) of the 23 of heart transplant recipients. At the best reconstruction interval, diagnostic image quality (score ≥ 2) was obtained in 92.1% (303 of 329) of the coronary artery segments. The mean image quality score for the whole coronary tree was 3.1 ± 1.01. No significant correlation between mean heart rate (ρ = 0.31) or heart rate variability (ρ = 0.23) and overall image quality score was observed (p = not significant). CONCLUSION. Dual-source CT acquisition yields coronary angiograms of diagnostic quality in heart transplant recipients. Mean heart rate and heart rate variability during scanning do not have a negative effect on the overall quality of images of the coronary arteries

Survival results of postoperative coronary angiogram for treatment of perioperative myocardial ischaemia following coronary artery bypass grafting:a single-centre experience

Abstract OBJECTIVES: Although perioperative myocardial ischaemia (PMI) is a well-known complication following coronary artery bypass grafting (CABG), standard strategies for its diagnosis and treatment are so far not defined. In this study, we sought to evaluate the impact on survival of postoperative coronary angiogram for management of patients with PMI after CABG. em>METHODS: Overall, 4028 patients underwent isolated CABG in a single-centre institution between January 2006 and September 2013. A total of 168 (4.2%) patients received postoperative coronary angiogram because of diagnosis of PMI. These patients were matched on the basis of gender, age at surgery and date of surgery, with 336 (1:2 ratio) CABG patients without PMI to determine the impact of the PMI management. RESULTS: A total of 476 grafts were examined (263 venous grafts, 196 internal mammary artery grafts and 17 radial artery grafts). Almost three-quarters of the 168 PMI (74.4%) patients underwent postoperative coronary angiogram within 24 h of surgery. Normal postoperative coronary angiogram, graft failure and new native vessels occlusion were observed in 23.2%, 52.4% and 24.4% of patients, respectively. A total of 30 (17.9%) patients underwent surgical revision of grafts, whereas 60 (35.7%) patients were treated with percutaneous coronary intervention. Eighteen (10.7%) PMI patients died during the hospital stay compared with 6 (1.8%) patients in the non-PMI group. Survival rates at 7 years were 62.5% in the PMI group and 81.1% in non-PMI group (P 24 h after surgery) was an independent predictor of poorer mid-term survival (P = 0.008; hazard ratio 3.62, 95% confidence interval 1.41–9.33). CONCLUSIONS: PMI after CABG is associated with a significantly poorer survival. A prompt postoperative management must always be considered. Further prospective studies are required to confirm our results