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

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 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

Quantification of left ventricular function and mass in heart transplant recipients using dual-source CT and MRI: initial clinical experience.

The purpose of this study was to compare LV function and mass quantification derived from cardiac dual-source CT (DSCT) exams with those obtained by MRI in heart transplant recipients. Twelve heart transplant recipients who underwent cardiac DSCT and MRI examination were included. Double-oblique short-axis 8-mm slice thickness images were evaluated. Left ventricular ejection fraction, end-diastolic volume, end-systolic volume, stroke volume, cardiac output and myocardial mass were manually assessed for each patient by two blinded readers. A systematic overestimation of all left ventricular volumes by DSCT when compared with MRI was observed. Mean difference was 16.58 +/- 18.61 ml for EDV, 4.9 4 +/- 6.84 ml for ESV, 11.64 +/- 13.58 ml for SV and 5.73 +/- 1.14 l/min for CO. Slightly lower values for left ventricular ejection fraction with DSCT compared with MRI were observed (mean difference 0.34 +/- 3.18%, p = 0.754). Correlation between DSCT and MRI for left ventricular mass was excellent (rho = 0.972). Bland and Altman plots and CCC indicated good agreement between DSCT and MRI left ventricular function and mass measurements. The interobserver correlation was good. In conclusion, DSCT accurately estimates left ventricular ejection fraction, volumes and mass in heart transplant recipients

Leucocyte- and platelet-rich fibrin (L-PRF) as a regenerative medicine strategy for the treatment of refractory leg ulcers: a prospective cohort study

Chronic wounds (VLU: venous leg ulcer, DFU: diabetic foot ulcer, PU: pressure ulcer, or complex wounds) affect a significant proportion of the population. Despite appropriate standard wound care, such ulcers unfortunately may remain open for months or even years. The use of leukocyte- and platelet-rich fibrin (L-PRF) to cure skin ulcers is a simple and inexpensive method, widely used in some countries but unknown or neglected in most others. This auto-controlled prospective cohort study explored and quantified accurately for the first time the adjunctive benefits of topical applications of L-PRF in the management of such refractory ulcers in a diverse group of patients. Forty-four consecutive patients with VLUs (n = 28, 32 wounds: 17 ≤ 10 cm(2) and 15 > 10 cm(2)), DPUs (n = 9, 10 wounds), PUs (n = 5), or complex wounds (n = 2), all refractory to standard treatment for ≥3 months, received a weekly application of L-PRF membranes. L-PRF was prepared following the original L-PRF method developed more than 15 years ago (400g, 12 minutes) using the Intra-Spin L-PRF centrifuge/system and the XPression box kit (Intra-Lock, Boca Raton, FL, USA; the only CE/FDA cleared system for the preparation of L-PRF). Changes in wound area were recorded longitudinally via digital planimetry. Adverse events and pain levels were also registered. All wounds showed significant improvements after the L-PRF therapy. All VLUs ≤ 10 cm(2), all DFUs, as well as the two complex wounds showed full closure within a 3-month period. All wounds of patients with VLUs > 10 cm(2) who continued therapy (10 wounds) could be closed, whereas in the five patients who discontinued therapy improvement of wound size was observed. Two out of the five PUs were closed, with improvement in the remaining three patients who again interrupted therapy (surface evolution from 7.35 ± 4.31 cm(2) to 5.78 ± 3.81 cm(2)). No adverse events were observed. A topical application of L-PRF on chronic ulcers, recalcitrant to standard wound care, promotes healing and wound closure in all patients following the treatment. This new therapy is simple, safe and inexpensive, and should be considered a relevant therapeutic option for all refractory skin ulcers.status: publishe

Leucocyte- and platelet-rich fibrin (L-PRF) as a regenerative medicine strategy for the treatment of refractory leg ulcers: a prospective cohort study

Chronic wounds (VLU: venous leg ulcer, DFU: diabetic foot ulcer, PU: pressure ulcer, or complex wounds) affect a significant proportion of the population. Despite appropriate standard wound care, such ulcers unfortunately may remain open for months or even years. The use of leukocyte- and platelet-rich fibrin (L-PRF) to cure skin ulcers is a simple and inexpensive method, widely used in some countries but unknown or neglected in most others. This auto-controlled prospective cohort study explored and quantified accurately for the first time the adjunctive benefits of topical applications of L-PRF in the management of such refractory ulcers in a diverse group of patients. Forty-four consecutive patients with VLUs (n = 28, 32 wounds: 17 ≤ 10 cm2 and 15 > 10 cm2), DPUs (n = 9, 10 wounds), PUs (n = 5), or complex wounds (n = 2), all refractory to standard treatment for ≥3 months, received a weekly application of L-PRF membranes. L-PRF was prepared following the original L-PRF method developed more than 15 years ago (400g, 12 minutes) using the Intra-Spin L-PRF centrifuge/system and the XPression box kit (Intra-Lock, Boca Raton, FL, USA; the only CE/FDA cleared system for the preparation of L-PRF). Changes in wound area were recorded longitudinally via digital planimetry. Adverse events and pain levels were also registered. All wounds showed significant improvements after the L-PRF therapy. All VLUs ≤ 10 cm2, all DFUs, as well as the two complex wounds showed full closure within a 3-month period. All wounds of patients with VLUs > 10 cm2 who continued therapy (10 wounds) could be closed, whereas in the five patients who discontinued therapy improvement of wound size was observed. Two out of the five PUs were closed, with improvement in the remaining three patients who again interrupted therapy (surface evolution from 7.35 ± 4.31 cm2 to 5.78 ± 3.81 cm2). No adverse events were observed. A topical application of L-PRF on chronic ulcers, recalcitrant to standard wound care, promotes healing and wound closure in all patients following the treatment. This new therapy is simple, safe and inexpensive, and should be considered a relevant therapeutic option for all refractory skin ulcers

Dual-source CT coronary imaging in heart transplant recipients: image quality and optimal reconstruction interval.

The image quality and optimal reconstruction interval for coronary arteries in heart transplant recipients undergoing non-invasive dual-source computed tomography (DSCT) coronary angiography was evaluated. Twenty consecutive heart transplant recipients who underwent DSCT coronary angiography were included (19 male, one female; mean age 63.1 +/- 10.7 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent observers assessed the image quality of each coronary segments using a five-point scale (from 0 = not evaluative to 4 = excellent quality). A total of 289 coronary segments in 20 heart transplant recipients were evaluated. Mean heart rate during the scan was 89.1 +/- 10.4 bpm. At the best reconstruction interval, diagnostic image quality (score > or = 2) was obtained in 93.4% of the coronary segments (270/289) with a mean image quality score of 3.04 +/- 0.63. Systolic reconstruction intervals provided better image quality scores than diastolic reconstruction intervals (overall mean quality scores obtained with the systolic and diastolic reconstructions 3.03 +/- 1.06 and 2.73 +/- 1.11, respectively; P < 0.001). Different systolic reconstruction intervals (35%, 40%, 45% of RR interval) did not yield to significant differences in image quality scores for the coronary segments (P = 0.74). Reconstructions obtained at the systolic phase of the cardiac cycle allowed excellent diagnostic image quality coronary angiograms in heart transplant recipients undergoing DSCT coronary angiography

Dual-source CT coronary imaging in heart transplant recipients: image quality and optimal reconstruction interval.

The image quality and optimal reconstruction interval for coronary arteries in heart transplant recipients undergoing non-invasive dual-source computed tomography (DSCT) coronary angiography was evaluated. Twenty consecutive heart transplant recipients who underwent DSCT coronary angiography were included (19 male, one female; mean age 63.1 +/- 10.7 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent observers assessed the image quality of each coronary segments using a five-point scale (from 0 = not evaluative to 4 = excellent quality). A total of 289 coronary segments in 20 heart transplant recipients were evaluated. Mean heart rate during the scan was 89.1 +/- 10.4 bpm. At the best reconstruction interval, diagnostic image quality (score > or = 2) was obtained in 93.4% of the coronary segments (270/289) with a mean image quality score of 3.04 +/- 0.63. Systolic reconstruction intervals provided better image quality scores than diastolic reconstruction intervals (overall mean quality scores obtained with the systolic and diastolic reconstructions 3.03 +/- 1.06 and 2.73 +/- 1.11, respectively; P < 0.001). Different systolic reconstruction intervals (35%, 40%, 45% of RR interval) did not yield to significant differences in image quality scores for the coronary segments (P = 0.74). Reconstructions obtained at the systolic phase of the cardiac cycle allowed excellent diagnostic image quality coronary angiograms in heart transplant recipients undergoing DSCT coronary angiography

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. © American Roentgen Ray Society

Dual-source CT coronary angiogram in heart transplant recipients in comparison with dobutamine stress echocardiography for detection of cardiac allograft vasculopathy.

Conventional coronary angiography (CCA) is the gold standard in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients. Dobutamine stress echocardiography (DSE) is a useful technique for screening. Dual-source computed tomography (DSCT) is the last generation of computed tomography scanners, which could be useful to noninvasively assess CAV. Thirty cardiac transplant recipients underwent DSE and DSCT coronary angiogram. Exclusion criteria were as follows: renal insufficiency, iodinated contrast media allergy, less than 12 months since transplant, and unstable clinical conditions. DSE showed ischemia in two patients. At DSCT scan 13 patients had a normal angiogram, 13 ones wall thickening and four significant diseases. DSCT showed a sensitivity of 100% with a specificity of 92%. DSCT allowed detection of more patients with CAV than DSE. Four patients showed significant CAV at DSCT compared with two at DSE. Thirteen patients showed initial signs of disease at DSCT despite a normal DSE