Controversias y avances en el uso clínico de asistencias ventriculares de flujo continuo de larga duración

[ES] Antecedentes: La incidencia y prevalencia de insuficiencia cardíaca (IC) está aumentando a proporciones epidémicas. La supervivencia mejorada en pacientes con IC, debido al éxito de los nuevos tratamientos, y el envejecimiento de la población ha contribuido a la creciente prevalencia de IC. Aunque el patrón oro de tratamiento para los estadios finales es el trasplante cardiaco, la escasez de donantes y el aumento de prevalencia de IC, ha hecho que, en los últimos años, la utilización de dispositivos de asistencia ventricular (DAV) haya experimentado un aumento exponencial. Sin embargo, el uso de estos dispositivos no está exento de complicaciones importantes y su elevado coste limita su uso. En este sentido, la selección adecuada de los pacientes que se puedan beneficiar de esta terapia es clave, y para ello, es vital investigar y aclarar que perfiles de pacientes pueden ser buenos candidatos y mejorar el seguimiento postimplante con el fin de detectar las posibles complicaciones y mejorar su tratamiento. El desarrollo de cirugías menos agresivas es una opción a abordar con el fin de disminuir la mortalidad precoz en estos pacientes. Objetivos: El objetivo general de los trabajos que conforman esta Tesis Doctoral es intentar aclarar algunas dudas que han ido surgiendo en los últimos años junto con la evolución de este tipo de DAV, permitiendo nuevos abordajes quirúrgicos gracias a la miniaturización de los mismos; así como la de probar su aplicabilidad en otro tipo de miocardiopatías mucho menos frecuentes que pueden tener consideraciones especiales, además de valorar la utilización de nuevas técnicas de imagen en el seguimiento de estos pacientes. Materiales y métodos: Esta Tesis Doctoral se compone de cuatro artículos publicados en revistas internacionales de alto factor de impacto, los cuales abordan diferentes controversias acerca del uso de DAV en pacientes con IC avanzada. Este proyecto surge de la colaboración creada entre dos centros universitarios, Medizinischen Hochschule Hannover (Alemania) y el Complejo Asistencial Universitario de Salamanca (España), con el fin de continuar desarrollando el mundo de los DAV. Resultados: En los pacientes > 70 años que se sometieron a un implante de un DAV se consiguió una supervivencia a los 2 años del 70,7%. La cirugía menos invasiva en este grupo de pacientes se asoció a una tasa de eventos postoperatorios reducida (reintervención quirúrgica por sangrado 7,1%, fallo ventricular derecho 14,3% y diálisis 14,3%) y una baja estancia hospitalaria en las unidades de cuidados críticos (6,4 ± 5,2 días). La cirugía menos invasiva en paciente que recibe un LVAD como terapia de destino presenta menos complicaciones postoperatorias que la cirugía convencional [menor hemorragia postoperatoria (0% vs. 26.9%, p <0.05) y tasas más bajas de apoyo inotrópico prolongado postoperatorio (15.0% vs 46.2%, p <0.05)] con una tendencia a mayor supervivencia a 2 años, (85,0% vs. 69,2%, p = 0,302). La tomografía computerizada cardiaca permite una mejor visualización del DAV y permite estimar de manera indirecta el gasto cardiaco suministrado por el DAV. En paciente con miocardiopatía no compactada, el implante de un DAV está asociado a una alta incidencia de episodios tromboembólicos, alcanzando el 60% en nuestra serie. Sin embargo no se observa una mayor incidencia de arritmias en esta población durante el seguimiento. Conclusiones: De los cuatro trabajos mencionados podemos extraer las siguientes conclusiones: 1. La edad no debe ser un factor determinante a la hora de valorar el implante de un DAVI. 2. La Tomografía Computerizada Cardiaca puede aportar ventajas en el seguimiento de pacientes con DAVI sobre la ecocardiografía convencional en diversas situaciones, con una mejor visualización de todos los componentes de dispositivo y como método de cálculo no invasivo del gasto cardiaco. 3. Existen miocardiopatías específicas asociadas a peor pronóstico tras el implante de un DAVI como son las miocardiopatías restrictivas y la no compactada. Estos pacientes podrían requerir terapias de antiagregación plaquetaria y un régimen de anticoagulación más agresivos que otro tipo de miocardiopatías. 4. La cirugía menos invasiva durante el implante de un DAVI es una opción factible y segura. Este abordaje puede aportar beneficios en el pronóstico de los pacientes al disminuir las complicaciones postoperatorias, en especial, reduciendo la incidencia de hemorragias postoperatorias y la tasa de fallo derecho

La responsabilidad extracontractual de las personas con discapacidad a la luz de la Ley 8/2021, de 2 de junio

[ES] Con la entrada en vigor de la Ley 8/2021, de 2 de junio, por la que se reforma la legislación civil y procesal para el apoyo a las personas con discapacidad en el ejercicio de su capacidad jurídica, se ha modificado el artículo 299 del Código Civil, estableciendo que la persona con discapacidad responderá por los daños causados a otros, de acuerdo con el Capítulo II del Título XVI del Libro Cuarto, sin perjuicio de lo establecido en materia de responsabilidad extracontractual respecto a otros posibles responsables. Una reforma, impulsada por la Convención sobre los derechos de las personas con discapacidad, hecho en Nueva York el 13 de diciembre de 2006, que ha suscitado dudas a cerca de la interpretación que merece, aumentando el debate que existía en la doctrina acerca de la responsabilidad de las personas con discapacidad.Para muchos, se introduce por fin el criterio de la culpabilidad objetiva, mientras que otros defienden la inexistencia de un cambio en el criterio de la culpabilidad.[EU] Ekainaren 2ko 8/2021 Legea, desgaitasunen bat duten pertsonei beren gaitasun juridikoa gauzatzean laguntzeko legeria zibila eta prozesala erreformatzen duena, indarrean sartzearekin batera, Kode Zibilaren 299. artikulua aldatu du, desgaitasuna duten pertsonek beste batzuei eragindako kalteengatik erantzungo dutela laugarren Liburuko XVI. Tituluko II. Kapituluaren araberae ezartzen, kontratuz kanpoko erantzunkizunaren arloan beste arduradun batzuei buruz ezarritakoa alde batera utzi gabe. 2006ko abenduaren 13an New Yorken egindako Desgaitasuna duten pertsonen eskubideei buruzko Konebntzioak bultzatutako erreforma bat, zer nolako interpretazioa merezi duen zalantzak sortu dituena, eta desgaitasuna duten pertsonen erantzunkizunari buruzko doktrinan zegoen eztabaida areagotu egin duena. Askoren ustez, erruduntasun objetibioaren irizpidea ezarri da, eta beste batzuk, berriz, erruduntasunaren irizpidearen ez aldaketa defendatzen dute

Dispersión urbana en el Suelo No Urbanizable del País Vasco: la distorsión del planeamiento en la Reserva de la Biosfera de Urdaibai

This article analyzes the process of urbanization that is registering the not-urban area in the Basque Country. Supported in the traditional dispersed rural habitat and legally protected by the “Rural Nucleus” urban figure referred to in the Basque Legislation, the urban sprawl is threatening the Basque territory, including protected areas. The analysis focuses on the progress of this phenomenon in the Urdaibai Biosphere Reserve, after a decade since the incorporation of the “Rural Nucleus” to the urban planning.[es] En este artículo se analiza el proceso de urbanización que está registrando el Suelo No Urbanizable en el País Vasco. Apoyado territorialmente en el tradicional hábitat rural disperso y amparado jurídicamente por la figura urbanística Núcleo Rural que contempla la [es]Legislación vasca, el urban sprawl amenaza al conjunto del territorio vasco, incluyendo sus espacios protegidos. El análisis se centra en el desarrollo del fenómeno en la Reserva de la Biosfera de Urdaibai, transcurrido un decenio desde la incorporación del Núcleo Rural al planeamiento urbanístico. [fr] Cet article analyse le processus d’urbanisation qui se déroule sur les terres classées comme “terrain non constructible” dans le Pays Basque. Territorialement tenue à la traditionnelle habitat rural et protégée par la figure urbanistique “Núcleo Rural”, etabliée par la loi basque, l’urban sprawl menace tout le Pays Basque, y compris ses aires protégées. L’analyse se concentre sur le développement du phénomène dans la Réserve de Biosphère d’Urdaibai, après une décennie depuis l’introduction de la figure “Núcleo Rural” à la planification urbaine

Repolarization parameters and ventricular arrhythmias in Takotsubo syndrome: A substudy from the RETAKO national registry

Arrhythmias; Repolarization; TakotsuboArritmias; Repolarización; TakotsuboArítmies; Repolarització; TakotsuboThe registry webpage was funded by an AstraZeneca nonconditioned grant and by FIC (Fundación Interhospitalaria para la Investigación en Cardiología)

Trigger‐Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Stress‐induced cardiomyopathy; Takotsubo syndromeMiocardiopatía inducida por estrés; Síndrome de takotsuboMiocardiopatia induïda per l'estrès; Síndrome de takotsuboBackground Takotsubo syndrome is usually triggered by a stressful event. The type of trigger seems to influence the outcome and should therefore be considered separately. Methods and Results Patients included in the GEIST (German‐Italian‐Spanish Takotsubo) registry were categorized according to physical trigger (PT), emotional trigger (ET), and no trigger (NT) of Takotsubo syndrome. Clinical characteristics as well as outcome predictors were analyzed. Overall, 2482 patients were included. ET was detected in 910 patients (36.7%), PT in 885 patients (34.4%), and NT was observed in 717 patients (28.9%). Compared with patients with PT or NT, patients with ET were younger, less frequently men, and had a lower prevalence of comorbidities. Adverse in‐hospital events (NT: 18.8% versus PT: 27.1% versus ET: 12.1%, P<0.001) and long‐term mortality rates (NT: 14.4% versus PT: 21.6% versus ET: 8.5%, P<0.001) were significantly lower in patients with ET. Increasing age (P<0.001), male sex (P=0.007), diabetes (P<0.001), malignancy (P=0.002), and a neurological disorder (P<0.001) were associated with a higher risk of long‐term mortality, while chest pain (P=0.035) and treatment with angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker (P=0.027) were confirmed as independent predictors for a lower risk of long‐term mortality. Conclusions Patients with ET have better clinical conditions and a lower mortality rate. Increasing age, male sex, malignancy, a neurological disorder, chest pain, angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker, and diabetes were confirmed as predictors of long‐term mortality

Smoking influence in Takotsubo syndrome: insights from an international cohort

Takotsubo syndrome; Mortality; Smoking habitSíndrome de Takotsubo; Mortalidad; Hábito de fumarSíndrome de Takotsubo; Mortalitat; Hàbit de fumarAims: To assess the influence of tobacco on acute and long-term outcomes in Takotsubo syndrome (TTS). Methods: Patients with TTS from the international multicenter German Italian Spanish Takotsubo registry (GEIST) were analyzed. Comparisons between groups were performed within the overall cohort, and an adjusted analysis with 1:1 propensity score matching was conducted. Results: Out of 3,152 patients with TTS, 534 (17%) were current smokers. Smoker TTS patients were younger (63 ± 11 vs. 72 ± 11 years, p < 0.001), less frequently women (78% vs. 90%, p < 0.001), and had a lower prevalence of hypertension (59% vs. 69%, p < 0.01) and diabetes mellitus (16% vs. 20%, p = 0.04), but had a higher prevalence of pulmonary (21% vs. 15%, p < 0.01) and/or psychiatric diseases (17% vs. 12%, p < 0.01). On multivariable analysis, age less than 65 years [OR 3.85, 95% CI (2.86–5)], male gender [OR 2.52, 95% CI (1.75–3.64)], history of pulmonary disease [OR 2.56, 95% CI (1.81–3.61)], coronary artery disease [OR 2.35, 95% CI (1.60–3.46)], and non-apical ballooning form [OR 1.47, 95% CI (1.02–2.13)] were associated with smoking status. Propensity score matching (PSM) 1:1 yielded 329 patients from each group. Smokers had a similar rate of in-hospital complications but longer in-hospital stays (10 vs. 9 days, p = 0.01). During long-term follow-up, there were no differences in mortality rates between smokers and non-smokers (5.6% vs. 6.9% yearly in the overall, p = 0.02, and 6.6%, vs. 7.2% yearly in the matched cohort, p = 0.97). Conclusions: Our findings suggest that smoking may influence the clinical presentation and course of TTS with longer in-hospital stays, but does not independently impact mortality.FIC (Fundación Interhospitalaria para la Investigación en Cardiología) supported RETAKO

Post-COVID-19 syndrome and diabetes mellitus: a propensity-matched analysis of the International HOPE-II COVID-19 Registry

SARS-CoV-2; Reinfection; Respiratory complicationsSARS-CoV-2; Reinfección; Complicaciones respiratoriasSARS-CoV-2; Reinfecció; Complicacions respiratòriesBackground: Diabetes mellitus (DM) is one of the most frequent comorbidities in patients suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with a higher rate of severe course of coronavirus disease (COVID-19). However, data about post-COVID-19 syndrome (PCS) in patients with DM are limited. Methods: This multicenter, propensity score-matched study compared long-term follow-up data about cardiovascular, neuropsychiatric, respiratory, gastrointestinal, and other symptoms in 8,719 patients with DM to those without DM. The 1:1 propensity score matching (PSM) according to age and sex resulted in 1,548 matched pairs. Results: Diabetics and nondiabetics had a mean age of 72.6 ± 12.7 years old. At follow-up, cardiovascular symptoms such as dyspnea and increased resting heart rate occurred less in patients with DM (13.2% vs. 16.4%; p = 0.01) than those without DM (2.8% vs. 5.6%; p = 0.05), respectively. The incidence of newly diagnosed arterial hypertension was slightly lower in DM patients as compared to non-DM patients (0.5% vs. 1.6%; p = 0.18). Abnormal spirometry was observed more in patients with DM than those without DM (18.8% vs. 13; p = 0.24). Paranoia was diagnosed more frequently in patients with DM than in non-DM patients at follow-up time (4% vs. 1.2%; p = 0.009). The incidence of newly diagnosed renal insufficiency was higher in patients suffering from DM as compared to patients without DM (4.8% vs. 2.6%; p = 0.09). The rate of readmission was comparable in patients with and without DM (19.7% vs. 18.3%; p = 0.61). The reinfection rate with COVID-19 was comparable in both groups (2.9% in diabetics vs. 2.3% in nondiabetics; p = 0.55). Long-term mortality was higher in DM patients than in non-DM patients (33.9% vs. 29.1%; p = 0.005). Conclusions: The mortality rate was higher in patients with DM type II as compared to those without DM. Readmission and reinfection rates with COVID-19 were comparable in both groups. The incidence of cardiovascular symptoms was higher in patients without DM

Post-COVID-19 Symptoms and Heart Disease: Incidence, Prognostic Factors, Outcomes and Vaccination: Results from a Multi-Center International Prospective Registry (HOPE 2)

COVID-19; Heart disease; PersistentCOVID 19; Malaltia cardíaca; PersistentCOVID-19; Enfermedad cardíaca; PersistenteBackground: Heart disease is linked to worse acute outcomes after coronavirus disease 2019 (COVID-19), although long-term outcomes and prognostic factor data are lacking. We aim to characterize the outcomes and the impact of underlying heart diseases after surviving COVID-19 hospitalization. Methods: We conducted an analysis of the prospective registry HOPE-2 (Health Outcome Predictive Evaluation for COVID-19-2, NCT04778020). We selected patients discharged alive and considered the primary end-point all-cause mortality during follow-up. As secondary main end-points, we included any readmission or any post-COVID-19 symptom. Clinical features and follow-up events are compared between those with and without cardiovascular disease. Factors with p < 0.05 in the univariate analysis were entered into the multivariate analysis to determine independent prognostic factors. Results: HOPE-2 closed on 31 December 2021, with 9299 patients hospitalized with COVID-19, and 1805 died during this acute phase. Finally, 7014 patients with heart disease data were included in the present analysis, from 56 centers in 8 countries. Heart disease (+) patients were older (73 vs. 58 years old), more frequently male (63 vs. 56%), had more comorbidities than their counterparts, and suffered more frequently from post-COVID-19 complications and higher mortality (OR heart disease: 2.63, 95% CI: 1.81–3.84). Vaccination was found to be an independent protector factor (HR all-cause death: 0.09; 95% CI: 0.04–0.19). Conclusions: After surviving the acute phase, patients with underlying heart disease continue to present a more complex clinical profile and worse outcomes including increased mortality. The COVID-19 vaccine could benefit survival in patients with heart disease during follow-up.Non-conditioned grant (Fundación Interhospitalaria para la Investigación cardiovascular, FIC. Madrid, Spain). This nonprofit institution had no role in the study design; collection, analysis, or interpretation of data; in the writing of the report; nor in the decision to submit the paper for publication

Clinical Profile and Determinants of Mortality in Patients with Interstitial Lung Disease Admitted for COVID-19

COVID-19; Interstitial lung diseases; MortalityCOVID-19; Malalties pulmonars intersticials; MortalitatCOVID-19; Enfermedades pulmonares intersticiales; MortalidadBackground: Concern has risen about the effects of COVID-19 in interstitial lung disease (ILD) patients. The aim of our study was to determine clinical characteristics and prognostic factors of ILD patients admitted for COVID-19. Methods: Ancillary analysis of an international, multicenter COVID-19 registry (HOPE: Health Outcome Predictive Evaluation) was performed. The subgroup of ILD patients was selected and compared with the rest of the cohort. Results: A total of 114 patients with ILDs were evaluated. Mean ± SD age was 72.4 ± 13.6 years, and 65.8% were men. ILD patients were older, had more comorbidities, received more home oxygen therapy and more frequently had respiratory failure upon admission than non-ILD patients (all p < 0.05). In laboratory findings, ILD patients more frequently had elevated LDH, C-reactive protein, and D-dimer levels (all p < 0.05). A multivariate analysis showed that chronic kidney disease and respiratory insufficiency on admission were predictors of ventilatory support, and that older age, kidney disease and elevated LDH were predictors of death. Conclusions: Our data show that ILD patients admitted for COVID-19 are older, have more comorbidities, more frequently require ventilatory support and have higher mortality than those without ILDs. Older age, kidney disease and LDH were independent predictors of mortality in this population

Infective endocarditis in patients with heart transplantation

[Background] The incidence of nosocomial and health care-related infective endocarditis (IE) is increasing. Heart transplantation (HT) implies immunosuppression and frequent health care contact. Our aim was to describe the current profile and prognosis of IE in HT recipients.[Methods] Multicenter retrospective registry-based study in Spain and France that included cases between 2008 and 2019.[Results] During the study period, 8305 HT were performed in Spain and France. We identified 18 IE cases (rate 0.2%). Median age was 57 years; 12 were men (67%). Valve involvement did not have a predominant location and three patients (16.7%) had atrial or ventricular vegetations without valve involvement. The median age-adjusted Charlson index was 4 (interquartile range 3–5). Eleven IE cases (61%) were nosocomial/health care-related. Median time (range) between HT and development of IE was 43 months (interquartile range 6–104). The major pathogens were Staphylococcus sp. (n = 8, 44%), Enterococcus sp. (n = 4, 22%), and Aspergillus sp. (n = 3, 17%). Although eight patients (44%) had a surgical indication, it was only performed in three cases (17%). Three patients (17%) died during the first IE hospital admission.[Conclusions] IE in HT recipients has specific characteristics. Valve involvement does not have a predominant location and non-valvular involvement is common. Three fifths have a nosocomial/health care-related origin. The major pathogens were staphylococci (44%), enterococci (22%), and Aspergillus (17%). In-hospital mortality was 17%.Peer reviewe