RESUMEN
Catheter ablation is a well-established therapeutic option for management of recurrent ventricular tachycardia in patients with ischemic/non-ischemic heart disease and procedural complications include a mortality rate of up to 3% and a risk of major complications up to 10%. Cardiac perforation following a catheter ablation is rare but serious complication and occurs in 1% of ventricular ablation procedures. The appropriate surgical repair may be challenging and need cardiopulmonary bypass support according to the location of the lesion and the hemodynamic status of the patient. We report the case of a free wall right ventricular perforation of the interventricular groove with cardiac tamponade following catheter ablation for recurrent ventricular tachycardia. Due to the proximity of the left anterior descending artery and the extreme fragility of tissues, the patient was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoSil®). This technique is a safe and effective surgical option to repair a ventricular perforation especially when the ventricular tissues are fragile. It is simple and enable to realize surgical repair also if the localization of tear is difficult to access and without the need for cardiopulmonary bypass support if hemodynamic conditions are stable.
Asunto(s)
Ablación por Catéter/efectos adversos , Endocardio/cirugía , Fibrinógeno/uso terapéutico , Lesiones Cardíacas/cirugía , Ventrículos Cardíacos/cirugía , Técnicas Hemostáticas/instrumentación , Trombina/uso terapéutico , Anciano de 80 o más Años , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/cirugía , Combinación de Medicamentos , Lesiones Cardíacas/diagnóstico , Lesiones Cardíacas/etiología , Lesiones Cardíacas/fisiopatología , Ventrículos Cardíacos/lesiones , Ventrículos Cardíacos/fisiopatología , Hemodinámica , Humanos , Masculino , Derrame Pericárdico/etiología , Derrame Pericárdico/cirugía , Resultado del TratamientoRESUMEN
Pulmonary artery aneurysm is a rare pathology and the optimal treatment approach remains unclear in the absence of clear guidelines. We report a case of pulmonary aneurysm and discuss the treatment options.
Asunto(s)
Aneurisma/cirugía , Implantación de Prótesis Vascular/métodos , Tereftalatos Polietilenos , Arteria Pulmonar , Anciano , Aneurisma/diagnóstico , Estudios de Seguimiento , Humanos , Masculino , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: The purpose of our study is to describe the use of recombinant factor VIIa (rFVIIa) in patients on central veno-arterial ECMO with a particular attention on associated thrombotic complications. STUDY DESIGN: Monocentric retrospective study. PATIENTS AND METHODS: We examined 91 files of patients on ECMO between 2005 and 2010. During this period, eight patients presented refractory bleeding and benefited from rFVIIa treatment. RESULTS: In six of the eight patients, the bleeding stopped. A decrease of the bleeding was noticed after the treatment of rFVIIa (before rFVIIa: 40.1±33.1mL/kg per 3 hours after rFVIIa: 5.4±3.2mL/kg per 3 hours (P=0.01). The transfusional needs were decreased after administration of rFVIIa. No thrombotic event was detected. Fibrinogen, d-dimers, platelet count and lactate were not modified by the treatment. Two patients were weaned from ECMO. One patient died 17 days after the weaning. The other patient survived without neurological damages. CONCLUSION: The rFVIIa is a treatment of exception for patients on central veno-arterial ECMO and could be a last-resort treatment in the presence of a not curable massive bleeding.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Factor VIIa/uso terapéutico , Hemorragia/tratamiento farmacológico , Adulto , Transfusión Sanguínea/estadística & datos numéricos , Resistencia a Medicamentos , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Fibrinógeno/metabolismo , Hemorragia/sangre , Hemorragia/terapia , Humanos , Lactante , Ácido Láctico/sangre , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Proteínas Recombinantes/uso terapéutico , Estudios Retrospectivos , Análisis de Supervivencia , Trombosis/sangre , Trombosis/complicaciones , Desconexión del VentiladorRESUMEN
OBJECTIVES: The present study was aimed at evaluating telomere length in blood and in different vascular tissues with or without atheroma, in 3 groups of subjects: a group of atherosclerotic subjects who underwent surgery (Atherosclerosis-Surgery), a second group of subjects with asymptomatic atherosclerotic carotid plaques but who did not undergo cardiovascular surgery (Atherosclerosis-No surgery), and a third group of subjects without atherosclerotic disease (Controls). The main objective was to determine if there is in vivo regulation of telomere length in situ by atherosclerotic lesions. METHODS: A total of 84 subjects (mean age 69 ± 8 years) were studied. Blood and arterial tissue telomere lengths were determined by Southern blotting. Personal medical history (diabetes, hypertension, cardiovascular disease, dyslipidemia), family medical history, drug intake, and lifestyle were evaluated in the entire population through the use of a questionnaire. RESULTS AND CONCLUSION: Arterial segments which did not develop atherosclerosis such as the saphenous vein and internal mammary artery, had longer telomere length than aortic segments. On the other hand, telomere length was shorter in aortic tissues which presented atherosclerotic lesions compared to corresponding tissues without atherosclerotic lesions. These results also suggest tissue regulation of telomere size by local factors likely related to oxidative stress responses.
Asunto(s)
Aterosclerosis/patología , Placa Aterosclerótica/patología , Telómero/química , Anciano , Anciano de 80 o más Años , Envejecimiento/patología , Arteriosclerosis/sangre , Aterosclerosis/sangre , Biomarcadores/sangre , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estrés Oxidativo , Placa Aterosclerótica/sangre , Factores de RiesgoRESUMEN
A cross-regulation between two regulatory T cell (T(reg) ) subsets [CD4(+) CD25(+) and invariant natural killer (NK) T - iNK T] has been described to be important for allograft tolerance induction. However, few studies have evaluated these cellular subsets in stable recipients as correlates of favourable clinical outcome after heart transplantation. T(reg) and iNK T cell levels were assayed by flow cytometry in peripheral blood samples from 44 heart transplant recipients at a 2-year interval in 38 patients, and related to clinical outcome. Multi-parameter flow cytometry used CD4/CD25/CD127 labelling to best identify T(reg) , and a standard CD3/CD4/CD8/Vα24/Vß11 labelling strategy to appreciate the proportions of iNK T cells. Both subtypes of potentially tolerogenic cells were found to be decreased in stable heart transplant recipients, with similar or further decreased levels after 2 years. Interestingly, the patient who presented with several rejection-suggesting incidents over this period displayed a greater than twofold increase of both cell subsets. These results suggest that CD4(+) CD25(+) CD127(low/neg) T(reg) and iNK T cells could be involved in the local control of organ rejection, by modulating immune responses in situ, in clinically stable patients. The measurement of these cell subsets in peripheral blood could be useful for non-invasive monitoring of heart transplant recipients, especially in the growing context of tolerance-induction trials.
Asunto(s)
Rechazo de Injerto/inmunología , Trasplante de Corazón/inmunología , Monitorización Inmunológica/métodos , Células T Asesinas Naturales/inmunología , Linfocitos T Reguladores/inmunología , Adolescente , Adulto , Anciano , Antígenos CD4/análisis , Antígenos CD4/inmunología , Antígenos CD8/análisis , Antígenos CD8/inmunología , Rechazo de Injerto/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Subunidad alfa del Receptor de Interleucina-2/análisis , Subunidad alfa del Receptor de Interleucina-2/inmunología , Subunidad alfa del Receptor de Interleucina-7/análisis , Subunidad alfa del Receptor de Interleucina-7/inmunología , Masculino , Persona de Mediana Edad , Células T Asesinas Naturales/efectos de los fármacos , Estudios Prospectivos , Adulto JovenRESUMEN
We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.
Asunto(s)
Ciclosporina/uso terapéutico , Rechazo de Injerto/prevención & control , Trasplante de Corazón/inmunología , Tacrolimus/uso terapéutico , Enfermedad Aguda , Suero Antilinfocítico/uso terapéutico , Biopsia , Presión Sanguínea , Creatinina/sangre , Rechazo de Injerto/tratamiento farmacológico , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Miocardio/patología , Factores de TiempoRESUMEN
OBJECTIVES: To assess the ability and safety of radiofrequency (RF) to induce cord thermal lesions using in-vitro perfused umbilical cords. METHODS: Nineteen human term umbilical cords were cannulated at both ends and perfused continuously with saline serum in a saline serum bath (37 degrees C). The RF electrode was then inserted into the cord close to the umbilical vein. Different RF power and temperature controls were applied to determine the optimal RF procedure in terms of cord tissue injury and safety in nine experiments. The safety of RF procedures was investigated in ten cords by measuring temperature changes at different sites close to the RF electrode insertion and the impact of RF on cord narrowing was evaluated by continuous monitoring of intraluminal pressure. Subsequent histopathological analysis was carried out in all cases. RESULTS: The optimal RF procedure reached a temperature of 100 degrees C in 10 min. RF produced a significant increase in intraluminal pressure (from 54.2 +/- 16.4 mmHg at baseline to 118.3 +/- 42.7 mmHg after 10 min, P < 0.05). There was no significant increase in temperature next to the site of insertion during the RF procedure. Histopathological analysis confirmed a > 30% decrease in cord and vein diameter. Cord tissue lesions were characterized by damage in the vessel walls and in the surrounding Wharton's jelly. CONCLUSION: Our results suggest that RF might be a feasible and safe technique to induce occlusion of umbilical vessels. Further in-vivo experiments are needed to assess its ability to induce a complete occlusion of the umbilical cord.
Asunto(s)
Ablación por Catéter/métodos , Embolización Terapéutica/métodos , Reducción de Embarazo Multifetal/métodos , Cordón Umbilical/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/instrumentación , Electrodos , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/instrumentación , Diseño de Equipo , Estudios de Factibilidad , Femenino , Calor , Humanos , Técnicas In Vitro , Embarazo , Reducción de Embarazo Multifetal/efectos adversos , Reducción de Embarazo Multifetal/instrumentación , Ultrasonografía Intervencional/métodos , Cordón Umbilical/fisiologíaRESUMEN
BACKGROUND: Telerobotic-assisted laparoscopic attempts to provide technological solutions to the inherent limitations of traditional laparoscopic surgery. The aim of this study is to report the first experience of two teams concerning telerobotic-assisted laparoscopic hysterectomy for benign and malignant pathologies. METHODS: This study included 14 patients at the University Hospital Saint Pierre of Brussels (Belgium) and 16 patients at the Cancer Center of Nancy (France) from September 1999 to July 2003. RESULTS: The indications for surgery were uterine malignant diseases in 12 cases (stade I) (41%), and benign pathologies of the uterus in 18 cases (59%). Five postoperative complications (17%) occurred, none related to the robotic system. CONCLUSION: Robotic surgery can be safely performed in gynecologic and gynecologic-oncologic surgery with no increase in complication rates. A significant advance is represented by the surgeon's ergonomic improvement.
Asunto(s)
Histerectomía/métodos , Laparoscopía/métodos , Robótica , Telemedicina , Enfermedades Uterinas/cirugía , Neoplasias Uterinas/cirugía , Adulto , Anciano , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Radiofrequency (RF) is a method of in situ destruction of liver tumor. Biliary complications are bile ducts stenosis or biliary abcess. The aim of this work was to study consequences of liver RF on bile ducts. METHODS: A porcine model of biliary lesions was created using radiofrequency ablation liver. Twenty-two pigs were used for the study. The RF RITA 1500 generator (RITA Medical Systems, Mountain View, Calif., USA) was used for all experiments. The needle was positioned under sonographic control in liver parenchyma beside bile ducts. Two lesions were performed in left liver. Four groups of 5 pigs were treated. The pigs were sacrificed 1 or 3 weeks after the procedure. Pringle maneuver was utilized in half of the RF procedures. An ex vivo cholangiogram was obtained by direct injection into the main bile duct. Samples of RF lesions of liver parenchyma near and at a distance from the RF lesions were taken for pathological studies. RESULTS: Radiological lesions were biliary stenosis, with or without upstream bile duct dilatation, or complete interruption of the bile duct, or extravasation of the radiological contrast agent. Histological lesions of bile ducts were observed near RF lesions and at distance of the RF lesions when a Pringle maneuver was used or when the liver was removed after 3 weeks. CONCLUSIONS: RF ablation in contact of the intrahepatic bile duct induced biliary lesions. Therefore, it is required to stay away from the bile duct or to protect it when performing RF ablation.
Asunto(s)
Enfermedades de los Conductos Biliares/etiología , Conductos Biliares Intrahepáticos/lesiones , Ablación por Catéter/efectos adversos , Animales , Enfermedades de los Conductos Biliares/diagnóstico por imagen , Enfermedades de los Conductos Biliares/patología , Conductos Biliares Intrahepáticos/diagnóstico por imagen , Conductos Biliares Intrahepáticos/patología , Constricción Patológica/etiología , Hígado , Modelos Animales , Radiografía , PorcinosRESUMEN
OBJECTIVE: To evaluate the experimental feasibility of laparoscopic computer-assisted pyeloplasty for pelvi-ureteric junction obstruction. MATERIALS AND METHODS: Fourteen pyeloplasties were undertaken in pigs using a laparoscopic transperitoneal approach and the robotic surgical system (da Vinci, Intuitive Surgical Inc., Sunnyvale, CA, USA). RESULTS: The robotic surgical system provides real-time three-dimensional stereoscopic vision. Manipulating the intracorporeal endo-wristed instruments from a remote console allows laparoscopic manoeuvres that are as easy as those during open surgery. Surgeons with no particular experience in laparoscopic surgery could learn complex surgery easily and quickly. CONCLUSION: This technique provides faster training and the possibility of undertaking complex laparoscopic procedures, especially reconstructive, with less fatigue for the surgeon.
Asunto(s)
Pelvis Renal/cirugía , Laparoscopía/métodos , Cirugía Asistida por Computador/métodos , Animales , Diseño de Equipo , Modelos Animales , Robótica , Stents , PorcinosRESUMEN
BACKGROUND: In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database. METHODS: The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors. RESULTS: Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival. CONCLUSION: Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.
Asunto(s)
Fibrinolíticos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/mortalidad , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/mortalidad , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Ensayos Clínicos Controlados como Asunto , Bases de Datos Factuales , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Francia/epidemiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Hipolipemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Sístole/efectos de los fármacos , Sístole/fisiología , Resultado del Tratamiento , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
OBJECTIVES: This study aimed to determine whether the myocardial T2 relaxation time, determined using a black-blood magnetic resonance imaging (MRI) sequence, could predict acute heart transplant rejection. BACKGROUND: The use of black-blood MRI sequences allows suppression of the confusing influence of blood signal when myocardial T2 is calculated to detect myocardial edema. METHODS: A total of 123 investigations, including cardiac MRI and myocardial biopsy, were performed 8 +/- 11 months after heart transplantation. Myocardial T2 was determined using an original inversion-recovery/spin-echo sequence. RESULTS: A higher than normal T2 (> or = 56 ms) allowed an accurate detection of the moderate acute rejections evidenced at baseline biopsy (> or = International Society for Heart and Lung Transplantation grade 2): sensitivity, 89% and specificity, 70% (p < 0.0001). T2 was increased in grade 2 (n = 11) compared with grade 0 (n = 49, p < 0.05), grade 1A (n = 34, p < 0.05) and grade 1B (n = 21, p < 0.05); T2 was further increased in grade 3 (n = 8) compared with grade 2 (p < 0.05). In addition, in patients without rejection equal to or greater than grade 2 at baseline, a T2 higher than normal (> or = 56 ms) was correlated with the subsequent occurrence of equal or greater than grade 2 rejection within the next three months: sensitivity 63% (12/19) and specificity 78% (64/82) (p = 0.001). CONCLUSIONS: Myocardial T2 determined using a black-blood MRI sequence, is sufficiently sensitive to identify most of the moderate acute rejections documented with biopsy at the same time, but is also a predictor of the subsequent occurrence of such biopsy-defined rejections.
Asunto(s)
Rechazo de Injerto/diagnóstico , Trasplante de Corazón/patología , Imagen por Resonancia Magnética/métodos , Adolescente , Adulto , Anciano , Ecocardiografía Doppler , Femenino , Trasplante de Corazón/diagnóstico por imagen , Trasplante de Corazón/inmunología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
We report a case of right ovarian strumal carcinoid tumor responsible for tricuspid regurgitation. Valve replacement and salpingo-oophorectomy were performed. Serotonin level and tomodensitometry were normal at 3-year follow-up. Rarity of strumal carcinoid tumor explains why this tumor has never been reported with carcinoid heart disease before.
Asunto(s)
Cardiopatía Carcinoide/etiología , Tumor Carcinoide/complicaciones , Neoplasias Ováricas/complicaciones , Anciano , Cardiopatía Carcinoide/diagnóstico , Cardiopatía Carcinoide/patología , Tumor Carcinoide/patología , Tumor Carcinoide/cirugía , Trompas Uterinas/cirugía , Femenino , Prótesis Valvulares Cardíacas , Humanos , Neoplasias Ováricas/patología , Neoplasias Ováricas/cirugía , Ovariectomía , Válvula Tricúspide , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
Plaques from the coronary arteries of explanted hearts showed massive calcification (15-fold increase) with a loss of scleroproteins (-36%), an increase in the collagen to elastin ratio (twofold) and activation (+15%) of matrix metalloproteinase-2 (MMP-2). Plaque-free portions of the coronary artery gave results similar to those obtained with the internal mammary artery. There was a significant correlation between plaque calcification and MMP-2 activation, suggesting that the two processes may be linked.
Asunto(s)
Enfermedad Coronaria/metabolismo , Metaloproteinasa 2 de la Matriz/metabolismo , Escleroproteínas/metabolismo , Adulto , Anciano , Calcinosis/metabolismo , Enfermedad Coronaria/patología , Vasos Coronarios/metabolismo , Vasos Coronarios/patología , Activación Enzimática , Matriz Extracelular/metabolismo , Matriz Extracelular/patología , Humanos , Persona de Mediana EdadRESUMEN
Complex interactions between the L-arginine/nitric oxide synthase (NOS) pathway and the sympathetic nervous system have been reported. Methods capable of measuring L-arginine and norepinephrine (NE) have mainly been reported for plasma. We report the use of the microdialysis technique combined with high-performance liquid chromatography (HPLC) for measurement of both L-arginine and NE within the same tissue microdialysis sample. The microdialysis probe consisted of linear flexible probes (membrane length: 10 mm, outside diameter: 290 microm, molecular weight cut-off 50 kDa). The method used for L-arginine measurement was HPLC with fluorescence detection, giving a within-run and a between-day coefficient of variation of 2.9 and 12.8%, respectively. The detection limit was 0.5 pM/20 microl injected for L-/D-arginine. The method used for NE measurement was HPLC with electrochemical detection. The coefficients of variation were 4% for within-assay precision and 7.5% for between-assay precision. The detection limit for NE was 1 fmol/20 microl injected. The microdialysis technique coupled with HPLC system was validated in vivo to measure muscular interstitial concentrations of both arginine and NE under baseline conditions and after intravenous infusion of 500 mg/kg of L-arginine or D-arginine. In conclusion, the microdialysis technique coupled to HPLC allows the simultaneous measurements of both L-arginine and NE within the same tissue microenvironment and will enable the study of the complex interactions between the L-arginine/NO pathway and sympathetic nervous system within the interstitial space of different organs.
Asunto(s)
Arginina/análisis , Cromatografía Líquida de Alta Presión/métodos , Músculos/química , Norepinefrina/química , Animales , Electroquímica , Hemodinámica , Masculino , Microdiálisis , Ratas , Ratas Wistar , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF. METHODS: The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction /=60%. Baseline variables were tested in Cox multivariate models. RESULTS: Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (
Asunto(s)
Cardiomiopatía Dilatada/diagnóstico , Insuficiencia Cardíaca/diagnóstico , Isquemia Miocárdica/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Cardiomiopatía Dilatada/clasificación , Cardiomiopatía Dilatada/mortalidad , Femenino , Francia , Insuficiencia Cardíaca/clasificación , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Isquemia Miocárdica/clasificación , Isquemia Miocárdica/mortalidad , Pronóstico , Análisis de SupervivenciaRESUMEN
BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF). METHODS AND RESULTS: An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [CI] 7.9-48.0), nonsinus cardiac rhythm (odds ratio 2.0, CI 1.2-3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, CI 1. 2-4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients. CONCLUSIONS: Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.