Agustín Albarrán González-Trevilla

Isquemia miocárdica demostrada secundaria a fístulas coronarias múltiples con drenaje en el ventrículo izquierdo

Los casos de isquemia miocardica demostrada debida a la presencia de fistulas coronarias multiples son escasos. Presentamos un caso de fistulas coronarias multiples dependientes de la descendente anterior, arteria circunfleja y coronaria derecha, con drenaje en el ventriculo izquierdo, responsables de isquemia demostrada mediante ergometria con talio. El diagnostico fue angiografico y su etiologia congenita. El control definitivo de los sintomas se consiguio con betabloqueantes y no con nitratos, en consonancia con el fenomeno de robo coronario como causante de la isquemia. There are few cases of demonstrated ischemia due to the presence of multiple coronary fistulae. We report a case of multiple coronary fistulae from left anterior descending, circumflex and right coronary arteries draining into the left ventricle, which were responsible for myocardial ischemia demonstrated with thallium stress test. They were diagnosed by coronary angiography, and their etiology seems to be congenital. The final control of symptoms was achieved with beta-blockers, and not with nitrates, which speaks for a «steal phenomenon» as the cause of ischemia.

Sequential Atrioventricular Pacing in Patients With Hypertrophic Cardiomyopathy: An 18-year Experience

INTRODUCTION AND OBJECTIVES Controversy persists regarding the role of sequential atrioventricular pacing in patients with obstructive hypertrophic cardiomyopathy and disabling symptoms. The aim of this study was to evaluate the effect of pacing on symptoms, dynamic gradient, and left ventricular function in patients with hypertrophic cardiomyopathy. METHODS From 1991 to 2009, dual-chamber pacemakers were implanted in 82 patients with obstructive hypertrophic cardiomyopathy and disabling symptoms despite optimal medical therapy. Sequential pacing was performed with a short atrioventricular delay. Clinical and echocardiographic parameters were measured before and immediately after implantation and after a long follow-up (median, 8.5 years [range, 1-18 years]). RESULTS The New York Heart Association functional class was immediately reduced after pacemaker implantation in 95% of patients (P < .0001), and this improvement was maintained until the final follow-up in 89% (P = .016). The gradient was significantly reduced after implantation (94.5 ± 36.5 vs 46.4 ± 26.7mmHg; P < .0001) and at final follow-up (94.5 ± 36.5 vs 35.9 ± 24.0mmHg; P < .0001). Mitral regurgitation permanently improved in 52% of the patients (P < .0001). There were no differences in ventricular thickness or diameters, ejection fraction, or diastolic function. CONCLUSIONS Sequential pacing in selected patients with obstructive hypertrophic cardiomyopathy improves functional class and reduces dynamic gradient and mitral regurgitation immediately after pacemaker implantation and at final follow-up. Prolonged ventricular pacing has no negative effects on systolic or diastolic function in these patients.

Role of Intravascular Ultrasound in Stent Thrombosis

Endoleaks are the most common late complications of endovascular repair of the descending aorta, with a reported incidence reaching 30% and a mean incidence of 13%. The incidence Servicio de Cirugı́a Cardiaca, Consorcio Hospital General Universitario de Valencia, Valencia, Spain Unidad de Radiologı́a Intervencionista, Consorcio Hospital General in our study was 25%. Type I endoleak tends to occur in patients whose underlying aortic disease is a dissection and the communication between the true and false lumen persists. Type II endoleak usually occurs in patients treated for an aortic aneurysm, and consists of repatency of the aneurysmal sac by collateral vessels. In our single case of this type of endoleak, the collateral originated from branches of the superior mesenteric artery that filled the proximal portion of the celiac trunk (occluded by the stent-graft, which covered the distal third of the descending thoracic aorta and the upper third of the abdominal aorta). Type III endoleak usually occurs in patients treated for an aortic aneurysm. In addition to structural failure of the stent-graft, the stress that the stent sustains due to aortic pulsatility or constriction of the aneurysmal sac can facilitate the development of endoleak. Type V endoleak consists of gradual expansion of the aneurysmal sac without an obvious endoleak. In conclusion, endoleaks are common following endovascular treatment of the descending aorta, and their noninvasive follow-up with multidetector computed tomography study is a feasible approach.

Tratamiento farmacológico en la fase aguda del infarto de miocardio. ¿Qué anticoagulante? ¿Qué antiagregante? ¿Qué otra medicación?

El tratamiento de la cardiopatia isquemica aguda ha evolucionado notablemente en las ultimas decadas, lo que ha contribuido a mejorar el pronostico de los pacientes. Un rapido diagnostico y un tratamiento precoz en la fase aguda del evento isquemico cardiaco suponen una mayor supervivencia y menor riesgo de desarrollar insuficiencia cardiaca, asi como otras complicaciones concomitantes. Asi pues, se ha demostrado que la administracion de ciertos farmacos anticoagulantes y antiagregantes, asi como bloqueadores beta, inhibidores de la enzima de conversion de angiotensina y estatinas, en la fase aguda del infarto, puede ayudar a mejorar la supervivencia y reducir el riesgo de complicaciones. En este articulo se revisa brevemente el tratamiento farmacologico inicial a administrar en las primeras 48 h de un infarto agudo de miocardio con elevacion del segmento ST.

Angioplastia primaria electiva en el shock cardiogénico: resultados de un estudio unicéntrico

Introduccion La presencia de shock cardiogenico es la principal causa de muerte intrahospitalaria en pacientes con un infarto agudo de miocardio. No se ha demostrado que los tratamientos convencionales mejoren la supervivencia de estos pacientes, y estudios previos de revascularizacion urgente con angioplastia coronaria parecen ofrecer resultados prometedores. Pacientes y metodo Se describen de forma retrospectiva los resultados clinicos y angiograficos de la angioplastia primaria electiva en 48 pacientes con shock cardiogenico secundario a un infarto agudo de miocardio de menos de 12 h de evolucion. Se utilizo contrapulsacion intraaortica en el 79% de los pacientes. Se excluyeron los enfermos con shock cardiogenico secundario a complicaciones mecanicas. Resultados Se obtuvo exito angiografico (estenosis final Conclusiones La revascularizacion coronaria urgente mediante angioplastia primaria e implante de stent intracoronario en pacientes con shock cardiogenico como complicacion de un infarto agudo de miocardio es efectiva, consigue restablecer un flujo TIMI ≥ 2 en una alta proporcion de pacientes y disminuye la mortalidad respecto a los resultados del tratamiento conservador en series historicas.

Enfoque terapéutico en la miocardiopatía hipertrófica obstructiva severa con enfermedad coronaria multivaso

La miocardiopatia hipertrofica obstructiva severa con enfermedad coronaria tiene una alta morbimortalidad quirurgica, mas aun cuando se presenta en pacientes mayores de 65 anos. Presentamos un abordaje terapeutico combinado para estas patologias. Presentamos a una paciente de 68 anos diagnosticada de miocardiopatia hipertrofica obstructiva en clase funcional 4 para angina y disnea a pesar de la administracion de 360 mg de propranolol. Se realiza Eco-Doppler y estudio hemodinamico con medicacion, objetivando miocardiopatia hipertrofica obstructiva severa con lesiones criticas proximales en arterias circunfleja y coronaria derecha y lesion moderada de arteria descendente anterior media. Se efectuo dilatacion e implantacion de stent de 3 ´ 15 mm en arteria circunfleja y dilatacion y colocacion de stent de 3,5 ´ 20 mm en coronaria derecha. Posteriormente se efectuo estudio hemodinamico basal y con estimulacion auriculoventricular que demostro la eficacia de la estimulacion bicameral con disminucion del gradiente. Se implanto marca-paso definitivo DDD. Se realizo Eco-Doppler post-implantacion. Se realizo control hemodinamico, coronariografia y Eco-Doppler a los 6 meses. Tanto la angioplastia coronaria como el tratamiento de la miocardiopatia hipertrofica obstructiva con estimulacion secuencial estan lo suficientemente contrastados como para poder ofrecer esta terapeutica combinada a los pacientes en que concurren ambas patologias, fundamentalmente en aquellos de alto riesgo quirurgico.

Left Main Dissection and Pseudoaneurysm Formation After a Road Traffic Accident

We present here the case of a 46-year-old man, a smoker, who was involved in a motor vehicle accident. He was hit by a car while driving his motorcycle. The emergency medical care team found that the patient had a Glasgow Coma Scale score of 3 and quickly developed a bradyasystolic cardiac arrest. After successful advanced resuscitation, the ECG showed right bundle-branch block and anterolateral ST-segment elevation (Figure 1), so the patient was transported to the intensive care unit. Figure 1. ECG after the cardiac arrest showing right bundle-branch block and anterolateral ST-segment elevation. First, a body computed tomography scan and x-ray were done, demonstrating jaw, rib, femur, and tibia fractures without any points of active bleeding. The right bundle-branch block disappeared but the ST-segment elevation persisted on ECG. In addition, an urgent echocardiogram detected wall motion abnormalities with an anteroseptal akinetic area and a moderately depressed ejection fraction without pericardial effusion (Movies I and II in the online-only Data Supplement). Consequently, an emergency coronary angiogram showed a thin radiolucent line in the distal left main coronary artery (LMCA) that suggested intimal flap (dissection) with Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the left anterior descending (LAD) artery and left circumflex artery (Figure 2A …

Dissection and ruptured pseudoaneurysm of a renal artery: a non-described complication during transcatheter aortic-valve implantation

A 72-year-old man with severe symptomatic aortic stenosis and multiple comorbidities (logistic Euroscore:10.29%) was rejected for conventional valvular surgery because of high surgical risk. After a thorough evaluation, a transcatheter aortic-valve implantation (TAVI) was performed by transfemoral access, and there were no immediate complications. After 72 h, the patient developed …