Ángel Sánchez-Recalde

Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation☆

OBJECTIVES We sought to determine the prevalence and rate of progression of left ventricular outflow tract obstruction (LVOTO) and aortic regurgitation (AR) in adults with discrete subaortic stenosis (DSS). BACKGROUND Discrete subaortic stenosis is an uncommon form of LVOTO, with rapid hemodynamic progression in children, but the prevalence and rate of progression in adults have not been studied so far. METHODS The prevalence of DSS was determined in 2,057 consecutive adults diagnosed with congenital heart disease (CHD). The relationship between LVOTO on Doppler echocardiography and patient age was analyzed. Sequential changes in LVOTO and AR were determined for patients with two or more Doppler echocardiograms obtained with at least a two-year interval. RESULTS A total of 134 adults (mean age 31 +/- 17 years) were diagnosed with DSS. The prevalence was 6.5% for all adults with CHD. Sixty patients (44%) had other associated CHD. The mean age of 29 patients who had undergone an operation for DSS during their adult life (56 +/- 15 years) was significantly higher than that of 64 patients (27 +/- 13 years) who had not required a surgical intervention (p < 0.0001). A significant relationship between LVOTO and patient age (r = 0.61, p < 0.0001) was found: 21 +/- 16 mm Hg in patients <25 years old, 51 +/- 47 mm Hg for those between 25 and 50 years old, and 78 +/- 36 mm Hg for those >50 years old. The LVOTO increased from 39.2 +/- 28 to 46.8 +/- 34 mm Hg (p = 0.01) during a mean follow-up of 4.8 +/- 1.8 years in 25 patients. The slope of the change in LVOTO was 2.25 +/- 4.7 mm Hg per year of follow-up. Aortic regurgitation was detected by color Doppler imaging in 109 patients (81%), but it was hemodynamically significant in <20%. An increase in the mean degree of AR over time was not significant (baseline: 1.3 +/- 0.8; follow-up: 1.5 +/- 0.9; p = 0.096). CONCLUSIONS The prevalence of DSS is increasing in adults due to the greater number of repaired CHDs that develop into evolutive DSS. In contrast to infants and children, adults with DSS show a slow rate of LVOTO progression. Aortic regurgitation is a common but usually mild and nonprogressive consequence. The current indications for surgical intervention should be revised.

Pheochromocytoma-Related Cardiomyopathy Inverted Takotsubo Contractile Pattern

A 41-year-old woman with no history of cardiac disease or hypertension was admitted to the intensive care unit with acute headache, psychomotor agitation, diaphoresis, nausea, and vomiting. A cerebral computed tomography scan ruled out subarachnoid hemorrhage. The ECG showed sinus tachycardia with ST-segment depression in leads V3–V6, II, III, and aVF. The troponin I level was elevated. The patient continued to have progressive respiratory deterioration, which required mechanical ventilation 24 hours after admission. She also developed 6 episodes of electromechanical dissociation, with circulatory recovery after successful cardiopulmonary resuscitation. Transthoracic echocardiography revealed severe left ventricular dysfunction and a contractile abnormality, …A 41-year-old woman with no history of cardiac disease or hypertension was admitted to the intensive care unit with acute headache, psychomotor agitation, diaphoresis, nausea, and vomiting. A cerebral computed tomography scan ruled out subarachnoid hemorrhage. The ECG showed sinus tachycardia with ST-segment depression in leads V3–V6, II, III, and aVF. The troponin I level was elevated. The patient continued to have progressive respiratory deterioration, which required mechanical ventilation 24 hours after admission. She also developed 6 episodes of electromechanical dissociation, with circulatory recovery after successful cardiopulmonary resuscitation. Transthoracic echocardiography revealed severe left ventricular dysfunction and a contractile abnormality, …

Images in cardiovascular medicine. Pheochromocytoma-related cardiomyopathy: inverted Takotsubo contractile pattern.

A 41-year-old woman with no history of cardiac disease or hypertension was admitted to the intensive care unit with acute headache, psychomotor agitation, diaphoresis, nausea, and vomiting. A cerebral computed tomography scan ruled out subarachnoid hemorrhage. The ECG showed sinus tachycardia with ST-segment depression in leads V3–V6, II, III, and aVF. The troponin I level was elevated. The patient continued to have progressive respiratory deterioration, which required mechanical ventilation 24 hours after admission. She also developed 6 episodes of electromechanical dissociation, with circulatory recovery after successful cardiopulmonary resuscitation. Transthoracic echocardiography revealed severe left ventricular dysfunction and a contractile abnormality, …A 41-year-old woman with no history of cardiac disease or hypertension was admitted to the intensive care unit with acute headache, psychomotor agitation, diaphoresis, nausea, and vomiting. A cerebral computed tomography scan ruled out subarachnoid hemorrhage. The ECG showed sinus tachycardia with ST-segment depression in leads V3–V6, II, III, and aVF. The troponin I level was elevated. The patient continued to have progressive respiratory deterioration, which required mechanical ventilation 24 hours after admission. She also developed 6 episodes of electromechanical dissociation, with circulatory recovery after successful cardiopulmonary resuscitation. Transthoracic echocardiography revealed severe left ventricular dysfunction and a contractile abnormality, …

Incidence and Predictors of Sudden Cardiac Arrest in Adults With Congenital Heart Defects Repaired Before Adult Life

Many adult survivors of repaired congenital heart disease (CHD) are at premature risk of death. Sudden cardiac arrest (SCA) is 1 of the leading causes of death but little is known about determinants for SCA in adults with repaired lesions. We sought to determine incidence and risk factors for SCA in a study population of 936 adults with previously repaired CHD who had completed follow-up at a single tertiary center during a mean period of 9 ± 7 years. Mean age at first examination in our institution was 21 ± 7 years. Diagnostic categories included tetralogy of Fallot (216), coarctation of the aorta (157), transposition complexes (99), single ventricle (55), and other CHD (409). During a total follow-up of 8,387 person-years, 22 patients (2.6 per 1,000 person-years) presented with SCA. Incidence of SCA varied widely between specific lesions; the highest incidence was observed in transposition complexes (10 per 1,000 person-years). Independent predictors of SCA were retrospectively identified using multivariate Cox proportional hazard modeling. Age at initial examination and severely impaired subaortic ventricular systolic function were independent risk factors for SCA (severe subaortic ventricular systolic dysfunction, adjusted hazard ratio 29, 95% confidence interval 11 to 72, p <0.001). SCA occurred in 23% of patients with severe subaortic ventricular systolic dysfunction versus 0.7% of patients with nonsevere decreased subaortic ventricular function (p <0.001). In conclusion, severe subaortic ventricular systolic dysfunction is a dominant multivariate predictor of SCA in an unselected population of adult survivors after surgery for CHD. Our data support the consideration of primary prevention strategies in these patients.

Risk of Aortic Root or Ascending Aorta Complications in Patients With Bicuspid Aortic Valve With and Without Coarctation of the Aorta

The actual incidence of ascending aorta complications (AACs) in adults with bicuspid aortic valve (BAV) and the role of associated coarctation of the aorta (COA) as an independent risk factor for AACs remain unknown. From the Adult Congenital Heart Disease database at La Paz Hospital, 631 patients in whom a BAV was diagnosed by echocardiography or surgical inspection since December 1989 were identified. These patients were then further subdivided into 2 groups according to the presence of an associated COA. AACs included aortic aneurysms (ascending aorta > or =55 mm) and aortic dissection, rupture, or perforation. Patients with a BAV and COA had a greater prevalence of AACs (8.0%) than those with an isolated BAV (3.7%; p = 0.037). The coexistence of COA was the only significant predictor of AACs (odds ratio 4.7, 95% confidence interval 1.5 to 15; p = 0.01). From the total patient group with a BAV, the clinical and echocardiographic data were reviewed for 341 patients without an AAC at baseline (97 with and 244 without COA) who had undergone serial examinations >1 year apart. The median follow-up was 7 years (interquartile range 3.5 to 10.2; total 2,436 patient-years). A new AAC occurred in 13 patients (0.5/100 patient-years). The incidence of AACs was 1.3/100 patient-years in the COA group versus 0.2/100 patient-years in the non-COA group (hazard ratio 7.5, 95% confidence interval 2.0 to 28, p = 0.002). All acute aortic events (dissection or rupture) at follow-up occurred in patients with a BAV and COA. In conclusion, the long-term incidence of AACs in patients with isolated BAV is low, but patients with BAV and associated COA are at increased risk.

Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions Results From the Chronic Coronary Occlusion Treated by Everolimus-Eluting Stent Randomized Trial

Background—Patients with coronary total occlusions are at especially high risk for restenosis and new revascularizations. Sirolimus-eluting stents dramatically improved the clinical outcome of this subset of patients in randomized trials, but other drug-eluting stents, mainly the everolimus-eluting stent (currently the most frequently used stent), have not yet been evaluated in patients with coronary total occlusions. The objective was to compare the second-generation everolimus-eluting stent with the first-generation sirolimus-eluting stent in patients with coronary total occlusions. Methods and Results—A total of 207 patients with coronary total occlusions and estimated time since occlusion >2 weeks were randomized to everolimus- or sirolimus-eluting stent. The primary end point was in-stent late loss at 9-month angiographic follow-up (noninferiority trial). Clinical follow-up was performed at 1 and 12 months. In-stent late loss at 9 months was 0.29±0.60 versus 0.13±0.69 mm in patients allocated to sirolimus- and everolimus-eluting stent, respectively. The observed difference in in-stent late loss between both groups was –0.16 mm (95% confidence interval, 0.04 to –0.36 mm; P for noninferiority <0.01). The rate of binary angiographic restenosis was 10.8% and 9.1% in patients allocated to sirolimus- and everolimus-eluting stent, respectively (P=0.709), whereas the rate of vessel reocclusion was 3.2% and 1.1%, respectively (P=0.339). At 12 months, the rate of major adverse events was 15.9% versus 11.1% with sirolimus- and everolimus-eluting stent, respectively (P=0.335), and probable or definitive stent thrombosis occurred in 3.0% and 0.0% of patients, respectively (P=0.075). Conclusions—In patients with coronary total occlusions, everolimus-eluting stent is as effective as sirolimus-eluting stent. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00793221.

Aspergillus Aortitis After Cardiac Surgery

OBJECTIVES The aim of this study was to describe the clinical characteristics of Aspergillus aortitis in a small series of consecutive patients. BACKGROUND Aspergillus infection of the ascending aorta after cardiopulmonary bypass surgery has rarely been reported and has always resulted in death. METHODS Aspergillus aortitis was confirmed by pathologic and microbiologic analysis in eight men (61 +/- 8 years) of 9,375 consecutive patients who underwent cardiac surgery between 1975 and 2000. RESULTS Patients presented with Aspergillus aortitis after aortic valve replacement (n = 5), coronary revascularization (n = 2), or both (n = 1). Initial symptoms appeared between the immediate postoperative period and up to two years after surgery. All patients had prolonged fever. Ante-mortem diagnosis was established in only three patients for whom transthoracic echocardiography was suggestive of aortic pseudoaneurysm and was confirmed by thoracic computed tomography or aortography. All patients had negative peripheral blood cultures. Seven patients died at short-term follow-up, and the one surviving patient was promptly treated by surgery and antifungal drugs. Pathologic examination confirmed Aspergillus aortitis with multi-organ dissemination without heart involvement in all patients except for two, in whom aortic valve endocarditis was found. Fungal cultures confirmed the presence of Aspergillus fumigatus in all patients. CONCLUSIONS Aspergillus aortitis is typically found after aortic valve or coronary surgery. It commonly leads to lethal multi-organ dissemination without involvement of the intracardiac structure. This entity should be considered in patients with persistent fever and negative blood cultures after open-heart surgery involving significant aortic wall damage, irrespective of the postoperative period.Objectives The aim of this study was to describe the clinical characteristics of Aspergillusaortitis in a small series of consecutive patients.

Implantación percutánea de prótesis valvulares aórticas en pacientes con estenosis aórtica severa sintomática rechazados para cirugía de sustitución valvular

La implantacion percutanea de protesis valvulares aorticas ha surgido recientemente como alternativa terapeutica en pacientes con estenosis aortica severa sintomatica rechazados para cirugia. Describimos la experiencia inicial con esta tecnica en nuestro centro. En 4 pacientes con estenosis aortica severa sintomatica rechazados para cirugia (euroSCORE medio, 23%) se realizo implantacion de protesis valvular aortica de Edwards-Sapiens por via transfemoral. En los 4 pacientes, el procedimiento tuvo lugar con exito, con implantacion correcta de la protesis y sin complicaciones. Al mes de seguimiento, no hubo eventos y todos los pacientes habian mejorado en su clase funcional.

Lower levels of in-stent late loss are not associated with the risk of stent thrombosis in patients receiving drug-eluting stents

AIMS The aim of this study was to evaluate whether there is any relationship between in-stent late loss (ISLL) and the risk of stent thrombosis (ST) in patients treated with drug eluting stents (DES). The benefit of DES in reducing binary angiographic restenosis and the need for new revascularisation procedures is due to a reduction on ISLL. It has been hypothesised, however, that neointimal hyperplasia could preclude ST, and thus a very low ISLL could increase the risk of ST. METHODS AND RESULTS We selected 26 randomised clinical trials comparing bare metal stents and DES or different DES types, and including clinical and angiographic follow-up. In order to evaluate the association between risk of ST and ISLL, meta-regression analyses were conducted, weighting for the number of patients of each study. Twenty-six studies were included, retrieving 36 subgroups for analysis and 8,971 patients treated with DES. The incidence for ST and LST was 0.81% and 0.17%. Using meta-regression techniques, neither the risk of ST nor the risk of LST were found to be significantly associated with ISLL, accounting for -0.82 and -0.002 meta-regression estimates respectively (IC 95%: -1.92 to 0.28 for ST and -0.008 to 0.003 for LST). CONCLUSIONS The risk of ST and LST after DES implantation is not related with ISLL values. A very low mean value of ISLL is nor associated with a higher risk of ST.

Endocarditis por Coxiella burnetii: evolución a largo plazo de 20 pacientes

Introduccion y objetivos Coxiella burnetii es una causa cada vez mas frecuente de endocarditis infecciosa de evolucion subaguda asociada a una elevada morbimortalidad. Nuestro objetivo fue analizar, en una serie de 20 pacientes, la evolucion clinica, serologica y terapeutica a largo plazo. Metodos Se estudiaron retrospectivamente 20 pacientes ingresados (13 varones y 7 mujeres con una edad media de 42 ± 10 anos) entre 1982 y 1996, que cumplian criterios de Duke modificados por Raoult para endocarditis por fiebre Q. Resultados La endocarditis asento sobre protesis valvular en 14 pacientes y sobre valvula nativa en 6. Todos excepto uno recibieron tratamiento antibiotico, presentando la doxiciclina en monoterapia peor resultado que combinada con otros farmacos. Fueron sometidos a recambio valvular 15 pacientes, siendo la causa mas frecuente la disfuncion protesica. La mortalidad global fue del 40% (8 pacientes). Actualmente, todos los pacientes mantienen valores de anticuerpos antifase I elevados tras un seguimiento entre 19 y 156 meses (media de 74 ± 47 meses). En 5 pacientes se suspendio el tratamiento antibiotico, dada la negatividad microbiologica valvular, permaneciendo asintomaticos tras 15-65 meses (32 ± 30) de seguimiento. Conclusiones La endocarditis por fiebre Q se asocia a un alto indice de complicaciones severas que requieren cirugia de sustitucion valvular. Todos los pacientes mantienen titulos serologicos elevados de forma cronica, sin otros datos de infeccion activa, lo que plantea la posibilidad de retirar el tratamiento en algun enfermo con negatividad valvular microbiologica y cuestiona el valor de la persistencia de una serologia anormal como monitorizacion del tratamiento.