Use of mycophenolate mofetil in patients with transplanted heart and renal insufficiency: the relevance of the pharmacokinetic study.
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Adult↗
Biomedical subjects
F Vallés
Publications and source records attributed to F Vallés.
The value of oxygen consumption in the prognosis of ambulatory patients suffering from chronic heart failure: its relevance in heart transplantation.
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Biomarkers↗
[Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts].
INTRODUCTION AND OBJECTIVES: Recurrence of infection is observed in a high proportion of patients who have had infective endocarditis in the past. The aim of our study was to evaluate the possible differences between the first and the recurrent episodes of endocarditis, as well as to assess the outcome and prognosis of patients with recurrent endocarditis. PATIENTS AND METHOD: We reviewed a series of 13 episodes of recurrent endocarditis from among 196 cases of infective endocarditis involving non-drug-addict patients in two hospitals from 1987 to 2000. RESULTS: There were no differences between recurrent and first episodes of endocarditis according to age, sex, heart valve involved or causal microorganisms. Prosthetic valve endocarditis was more common in patients with recurrent endocarditis (86% versus 27%; p < 0.001). Although there were no differences in the rate of complications or early surgery, overall mortality was significantly higher in patients with recurrent endocarditis (53% versus 27%: p < 0.05). When early and late mortality were analysed separately, the differences did not achieve significance. CONCLUSIONS: Recurrent endocarditis was frequent in our series (7% of all cases). The features were similar to those of the first episode except for a higher rate of prosthetic valve endocarditis and a higher overall mortality.
Endocarditis, Bacterial↗
[Practice guidelines of the Spanish Society of Cardiology on endocarditis].
Infectious endocarditis is a disease which mainly involves the cardiac valves. It has a bad prognosis and is caused by a great variety of microorganisms. Prophylaxis is important although the effectiveness and the best way to achieve it remain unclear. Recommendations are herein presented. The diagnosis is based on clinical, bacteriological, and echocardiographic findings mainly based on Duke's criteria. Transthoracic and transesophageal echography are not only of diagnostic value but are also a tool to determine the therapy to follow. Antibiotic therapy should be selected according to the organisms isolated and their in vitro susceptibility. Guidelines for empirical antibiotic therapy in cases of negative cultures are also included. Lastly, indications and time for surgery are discussed.
Anti-Bacterial Agents↗
Long term outcome of infective endocarditis in patients who were not drug addicts: a 10 year study.
OBJECTIVE: To determine the clinical features and long term prognosis of infective endocarditis in patients who were not drug addicts. DESIGN: Prospective case series. SETTING: A university hospital that is both a referral and a primary care centre. PATIENTS: 138 consecutive cases of infective endocarditis diagnosed and treated from January 1987 to March 1997. RESULTS: Mean patient age was 44 (20) years old. 95 patients (69%) had native valve endocarditis and 43 (31%) had prosthetic valve endocarditis. Staphylococci were the causal microorganisms in 34% of cases and streptococci in 33%. Severe complications occurred in 83% of patients and 51% of patients underwent surgery during the active phase (22% was emergency surgery). Inpatient mortality was 21%. During a follow up of 56 (44) months, 10 patients (9%) needed late cardiac surgery and seven (5% of the whole series) died. Overall 10 year survival was 71%. There were no significant differences in survival depending on the type of treatment received during the hospital stay (medical or combined medical-surgical). CONCLUSIONS: A high early surgery rate is related to good long term results and does not increase in-hospital mortality. Medical treatment, however, also offers favourable long term results in cases of responsive infective endocarditis where poor prognostic factors are absent.
Adult↗
[Heart failure caused by severe systolic ventricular dysfunction of hypertensive origin. Long-term clinical and functional course].
AIMS: The aims of our study were to evaluate survival and evolution of functional class and ventricular function in patients with severe congestive heart failure due to dilated cardiomyopathy. METHODS: Inclusion criteria were: class III or IV heart failure, dilated left ventricle with ejection fraction < 40%, history of poor controlled hypertension, and exclusion of other etiologies for heart failure. We studied 17 patients with these features; mean age was 64 +/- 7 years and 70% were male. They were followed up during a mean period of 3.3 +/- 1 years (2 to 6; median 3 years). RESULTS: Baseline left ventricular ejection fraction was 30 +/- 5% (20 to 40); 35% of patients were in functional class III and 65% in class IV; 100% of patients received ACE inhibitors and diuretics, 53% betablockers, and 35% calcium-antagonists. Survival was 100%. Left ventricular ejection fraction increased from 30 +/- 5% to 44 +/- 11% at one year, to 50 +/- 11% at 3 years and 51 +/- 10% at the end of follow-up (p < 0.001). This improvement was mainly due to a reduction in systolic left ventricular diameter (from 51 +/- 4 mm to 42 +/- 11 mm, p < 0.01), since diastolic diameter did not significantly changed (63 +/- 4 to 59 +/- 11 mm). CONCLUSIONS: The evolution of severe systolic left ventricular dysfunction due to arterial hypertension is favourable at long-term, with null mortality and clinical ejection fraction and functional improvement. Nevertheless, the persistence of left ventricular dilatation suggests that myocardial damage caused by chronic pressure overload does not disappear.
Aged↗
[Aortic valve replacement with pulmonary autograft (the Ross procedure) in adult and pediatric patients].
Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180-620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 +/- 12.6 years. Five patients were pediatrics (<= 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (>= grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 +/- 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 +/- 32 a 95.8 +/- 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significantly, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our series, are excellent after the Ross procedure.
Adult↗
[Practice guidelines of the Spanish Society of Cardiology. Cardiac and heart-lung transplants].
Cardiac transplantation is the only therapy that is able to substantially modify the natural evolution of patients with severe heart failure, along with angiotensin converting enzyme inhibitors. Nevertheless, because of the limited number of donors, its impact is scarce compared to the magnitude of the problem. Up to the end of 1998, 48,541 orthotopic cardiac transplantations and about 2,510 heart and both lung transplantations have been registered throughout the world. In Spain 2,780 procedures have been performed in the last 15 years. The survival expectations for a transplanted patient is 75% after the first year and 60% the following 5 years. The average duration of the graft is 8 years and 6 months. Cardiac transplantation is indicated for young and middle-age patients with irreversible cardiac process in bad clinical condition, with no other possibility of medical or surgical management and with a limited life expectancy. The major debate when choosing this therapy appears with the critical patients, patients older than 65 years, and some patients with systemic diseases. The great demand of transplantation obliges the teams to enlarge the criteria for donors' acceptance. At the same time, the increase of the knowledge about the transmission of some infections, mainly viral, forces to review those criteria day-to-day. The use of different immunosuppressive strategies pursues the control of rejection. The most commonly used is the so-called triple therapy (cyclosporine-azathioprine and steroids). The use of antilymphocytic antibodies such as cytolytic induction treatment is not unanimously accepted. Some of the new immunosuppressive agents such as myphenolate-mofetil and tacrolimus seem to offer advantages mainly due to their greater potency. Since transplantation is a limited procedure, of which its practise has an effect on the whole health system of a country, a perfect planning and adequacy of the Centers is compulsory, as well as the setting-up of clear rules for the use of donors and priority of transplantation. Finally, the patient must be informed clearly and comprehensively at length of the risks, limitations and expectations of these complex procedures.
Biopsy↗
[Etiopathogenesis of infective endocarditis: predisposing heart diseases and causal microorganisms].
Infective endocarditis is caused by the infection of an amorphous mass of platelets and fibrin (the so-called nonbacterial thrombotic endocarditis) which involves a damaged endothelial surface of the heart. Several pathogenetic mechanisms (hemodynamic, immunological, microbiological, etc.) are needed for the development of endocarditis. We review some of these mechanisms, as well as possible changes in etiopathogenesis of this disease that have recently occurred.
Endocarditis, Bacterial↗
[Clinical manifestations of infective endocarditis].
Infective endocarditis has a broad clinical picture, with systemic and multiorgan impairment. The organs most frequently involved are the heart, the central nervous system and the kidneys. Complications are caused by several mechanisms: direct effect on the heart, septic embolisms and immunological phenomena. We review some of the main clinical aspects of this disease, as well as the results of a wide series of patients with infective endocarditis from our hospital.
Aged↗
Comparison of bezafibrate versus lovastatin for lowering plasma insulin, fibrinogen, and plasminogen activator inhibitor-1 concentrations in hyperlipemic heart transplant patients.
Accelerated coronary artery disease is the most serious obstacle to long-term survival in heart transplant recipients. Hyperlipemia, hyperinsulinism, and changes in endothelial cell hemostatic function have been implicated in cardiac allograft vascular disease. Both lovastatin and bezafibrate are safe, effective, and well tolerated therapies for hyperlipidemia. Our study compares the effect of these lipid-lowering drugs in 21 patients with post-heart transplantation hyperlipidemia on different risk factors related to insulin resistance syndrome. Patients were given the same diet for 3 months, then randomized to lovastatin or bezafibrate for a period of 8 weeks, and crossed over to an additional 8 weeks of either bezafibrate or lovastatin. Baseline parameters were also compared with those of a control group of healthy subjects and after both periods of pharmacologic treatment. Transplant patients had higher insulin (35 +/- 3 vs 24 +/- 3 microIU/L), fibrinogen (298 +/- 15 vs 261 +/- 14 mg/dl), and plasminogen activator inhibitor-1 (PAI-1) (17 +/- 2 vs 11.7 +/- 2 arbitrary units/ml) plasma levels than controls. Significant decreases in insulin (-37 +/- 3%), fibrinogen (-12 +/- 4%), and PAI-1 plasma levels (-18 +/- 12%) were only observed after bezafibrate treatment. In conclusion, bezafibrate decreases plasma insulin, fibrinogen, and PAI-1 in hyperlipidemic heart transplant recipients.
Bezafibrate↗
[Characteristics and course of patients over 65 years of age with severe heart failure].
INTRODUCTION AND OBJECTIVES: Although there have been many studies on the prognosis of congestive heart failure, most of them have not provided specific data about older patients. The aim of our study is to evaluate general characteristics and short and medium-term evolution of patients older than 65 years with severe heart failure. PATIENTS AND METHODS: We have carried out a prospective study of all patients older than 65 years admitted to our Department during 1993 due to severe heart failure (functional class III or IV of the NYHA classification), regardless of the etiology. In that year, 84 patients who fulfilled those criteria were admitted. RESULTS: The mean age was 72 +/- 6 years, 56% were male and 44% female. Age distribution was as follows: 36 patients were between 65 and 70 years, 27 between 70 and 75, 8 between 75 and 80, and 13 older than 80. The etiology of heart failure was: ischemic heart disease 44%, valvular heart disease 36%, idiopathic dilated cardiomyopathy 8%, systemic arterial hypertension 7% and other etiologies 5%. Significant systolic dysfunction (left ventricular ejection fraction < 0.45) was present in 36% of the patients. Ten percent of the patients suffered from severe ventricular arrhythmias (ventricular tachycardia or fibrillation). Regarding treatment, 24% underwent valvular surgery, 74% received only medical treatment and coronary angioplasty was performed in one patient. In hospital mortality was 9% (8 patients). After a mean follow-up of 8 +/- 4 months, the probability of survival was 78% at 1 month, 71% at 6 months and 63% at 1 year. The survival rate was better in patients with higher ejection fraction (53% for patients with ejection fractions of less than 0.45, 64% for those with ejection fractions between 0.45 and 0.60 and 79% for those with ejection fractions greater than 0.60). Considering etiology, the survival rate was worse for patients with acute myocardial infarction (30%) and aortic valve stenosis (58%). CONCLUSIONS: Patients older than 65 years admitted to the hospital for severe congestive heart failure represent a heterogeneous population in respect to etiology, systolic function and prognosis. Nevertheless, from this study it appears that a worse prognosis was associated with the lower left ventricular ejection fractions and with certain etiologies; such as acute myocardial infarction or aortic stenosis.
Age Factors↗
[Value of a short (7 days) prophylactic course of ganciclovir in the prevention of cytomegalovirus disease after heart transplantation].
BACKGROUND: The incidence of cytomegalovirus disease remains important after heart transplantation, mainly in the first months after transplantation. We undertook a study to evaluate a short (7 days) prophylactic administration of ganciclovir to prevent cytomegalovirus disease after heart transplantation. PATIENTS AND METHODS: There were two groups of patients: patients transplanted in 1993 (37) and patients transplanted in 1992 (38). In the first group, ganciclovir was given intravenously at a dose of 10 mg per kilogram of body weight every day from postoperative day 1 through day 7. In the second group, ganciclovir was not given. Similar regimens of immunosuppression (ATG, deflazacort, azathioprine and cyclosporine) were given. RESULTS: Age, sex, serology in recipients and donors and incidence of acute rejection were comparable between both groups. Mortality was slightly higher in ganciclovir group (35%) than in control group (26%), although this difference was not statistically significant. There were two cases of cytomegalovirus disease in the ganciclovir group (6%) and nine cases in the control group (27%) (p < 0.05), all of them treated successfully. Cytomegalovirus disease in ganciclovir group occurred in two children, who were seronegative before transplantation. The incidence of cytomegalovirus disease in the pediatric recipients of ganciclovir group were 50% (2 of 4) and 100% in the control group (1 of 1). The incidence of cytomegalovirus disease were therefore 0% in the adult subgroup of ganciclovir group and 24% in the adult subgroup of control group. CONCLUSIONS: A short (7 days) prophylactic administration of ganciclovir reduces the incidence of cytomegalovirus disease. In the pediatric group, the effectiveness is lower.
Adult↗
[Long-term clinical course of acute myocarditis. Prospective study of a series of 99 patients (1987-1995)].
BACKGROUND: The natural history of acute myocarditis is not well known. The aim of our study was to assess the spontaneous outcome of patients with this disease and its possible relation with progression to chronic dilated cardiomyopathy. METHODS: With this aim, we have carried out a prospective study of 99 patients consecutively diagnosed with acute myocarditis in our hospital from 1987 to April 1995, with a mean follow-up of 34 +/- 25 months. Acute myocarditis was diagnosed by clinical, echocardiographic and isotopic (detection of myocite damage) data, in absence of any other cardiac lesion. RESULTS: Mean age was 26 +/- 17 years; 70% of the patients were male. Initial symptoms were dyspnea in 58% of the patients, chest pain in 33% and arrhythmias in 9%. Severe heart failure was present in 62% of the patients, ventricular arrhythmias in 16% and supraventricular arrhythmias in 16%. Cardiothoracic index was 0.50 +/- 0.07. Left ventricular ejection fraction was 0.40 +/- 0.18, although in 44% of the patients it was lower than 0.30. Immunosuppressive therapy was not used in any case. Outcome was favorable in 70% of the patients, who had a normal ejection fraction, while 13% died or needed heart transplantation during follow-up and 17% progressed to stable chronic dilated cardiomyopathy. Final ejection fraction was 0.53 +/- 0.17, significantly higher than the initial, 0.40 +/- 0.18 (p < 0.05); this improvement in ejection fraction was mainly observed during the first month after diagnosis (0.49 +/- 0.18). The proportion of patients with an ejection fraction of less than 0.30 decreased from 44% to 21% at the end of follow-up. CONCLUSIONS: Spontaneous outcome of acute myocarditis is good in the majority of patients, although an unfavourable evolution was observed in almost 30% of the patients (death, need of heart transplantation or chronic dilated cardiomyopathy). Improvement in ventricular function mainly occurs at short-term, during the first month of evolution in our study.
Acute Disease↗
[Myocardiopathies (XIII). Markers of clinical course in patients with dilated myocardiopathy].
The natural history of dilated cardiomyopathy, above all in asymptomatic patients, is not easily predictable. Nevertheless, when congestive heart failure is present, prognosis is significantly worse. The development of new therapeutic methods, both pharmacological (angiotensin converting enzyme inhibitors and other drugs) and surgical (heart transplantation), have improved the prognosis of this disease. In this article, we review some subjects of interest related to the management and treatment of patients with dilated cardiomyopathy that have been studied recently: identification of potentially reversible causes, optimization of medical therapy, prognostic markers, identification of high-risk patients and selection of candidates for heart transplantation.
Cardiomyopathy, Dilated↗
Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis.
To assess the incidence of a specific etiology and the role of methods for specific etiologic diagnosis in patients with primary acute pericarditis, we studied 100 patients with primary acute pericarditis consecutively admitted to our hospital between 1991 and 1993. A general diagnostic protocol was performed in all patients, whereas only pericardiocentesis was performed in patients with clinical cardiac tamponade or an unfavorable course with anti-inflammatory drugs. Surgical drainage and pericardial biopsy was performed in patients with tamponade relapse. A specific etiology was discovered in 22 patients (22%) (neoplasms in 7, tuberculosis in 4, other infections in 3, collagen diseases in 3, thyroid disorders in 4, and dissecting aortic aneurysm in 1). The general diagnostic protocol led to a specific diagnosis in 15 patients (68% of all patients with specific acute pericarditis) and pericardiocentesis in the other 7 patients (32%). The role of a diagnostic protocol, therapeutic pericardiocentesis, and diagnostic pericardiocentesis was similar and complementary. Pericardial biopsy results were negative in the 5 patients in whom it was performed. Cardiac tamponade and an unfavorable clinical outcome were significantly (p < 0.001) associated with the finding of a specific etiology; when both features were combined, sensitivity was 86% and specificity 85%, positive predictive value 63% and negative predictive value 96%. We conclude that the specific etiology in patients with primary acute pericarditis is about 20% to 25%, and that about 90% of these specific cases can be discovered by using the described systematic diagnostic protocol only in patients with an unfavorable outcome (cardiac tamponade or poor clinical course).
Acute Disease↗
[For whom and when is a heart transplant indicated].
Selection of receptor has a great importance in the field of heart transplantation, due to its influence on short and long-term results after transplantation and to a better profit of available donors and resources. Although several parameters of prognostic value in patients with severe heart failure have been suggested, the indication and timing of heart transplantation are still based on a accurate assessment of contraindications or risk factors in the receptors, as well as on the clinical and functional condition of patients while receiving an adequate medical therapy.
Adult↗
Comparison of the effectiveness of lovastatin therapy for hypercholesterolemia after heart transplantation between patients with and without pretransplant atherosclerotic coronary artery disease.
With the aim of assessing the effectiveness and safety of lovastatin in patients with hypercholesterolemia after heart transplantation, as well as the potential differences in the lipid-lowering effect of lovastatin between patients with or without pretransplant coronary artery disease (CAD), we studied 63 heart transplant patients who had serum total cholesterol > 250 mg/dl in spite of dietary therapy. Mean age of subjects was 47 +/- 2 years. Triple-drug immunosuppressive therapy consisted of cyclosporine, azathioprine, and steroids. Thirty-nine patients (62%) had pretransplant CAD and 24 (38%) did not. Pretreatment serum lipid levels were: total cholesterol, 302 +/- 32 mg/dl; low-density lipoprotein (LDL) cholesterol, 201 +/- 35 mg/dl; high-density lipoprotein (HDL) cholesterol, 60 +/- 19 mg/dl; triglycerides, 205 +/- 86 mg/dl; and total/HDL cholesterol ratio, 5.4 +/- 1.6. Patients received 10 to 40 mg/day of lovastatin (mean dose 17 +/- 6) for 13 +/- 4 months. There were no serious adverse events. At 3 months, lovastatin decreased total cholesterol by 15% (p < 0.001), LDL cholesterol by 21% (p < 0.001), triglycerides by 17% (p < 0.05), and total/HDL cholesterol ratio by 17% (p < 0.001), and increased HDL cholesterol by 3% (NS). Although lovastatin was effective in both patients with pretransplant CAD and non-CAD, analysis of its effect in each subgroup (CAD and non-CAD) revealed that its lipid-lowering effect was higher for non-CAD patients (-20% vs -12% for total cholesterol, and -27% vs -17% for LDL cholesterol, both p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Cholesterol↗