Augusto Torino

Predictores de mortalidad hospitalaria en 186 episodios de endocarditis infecciosa activa en un centro de tercer nivel (1992-2001)

Introduction and objectives. The aim of this study was to describe the predictors of hospital mortality found in patients admitted for infective endocarditis (IE) to a cardiovascular surgery ward. Patients and method. Prospective study of 186 patients with IE treated in our hospital between 1992 and 2001. Results. One hundred fourteen patients (61.3%) had native valve endocarditis and 72 (38.7%) had prosthetic valve endocarditis (early in 28 patients [up to 12 months after surgery] and late in 44 [later than 12 months]). Blood cultures were positive in 82%. The predominant organism was Streptococcus viridans (36%) in native valve endocarditis and Staphylococcus aureus (33%) in prosthetic valve endocarditis. The hospital mortality was 22.6%. Severe sepsis (4.8%) produced a high mortality rate (88%) and was caused by Staphylococcus aureus in 60%. One hundred nineteen patients (64%) required surgery, 79 (66.4%) of them urgently. Negative blood cultures predicted need for surgery in native valve endocarditis (p < 0.05). The surgical mortality was 21.8% and was related to NYHA III-IV class (p = 0.014) and emergency surgery (p = 0.009) in patients with native valve endocarditis. This last factor also predicted higher surgical mortality in patients with early prosthetic valve endocarditis (p < 0.001). Conclusions. The hospital mortality of this group of patients with infective endocarditis treated in a tertiary medical center was high. The presence of severe sepsis, although infrequent, had a somber prognosis. Severe heart failure in native valve endocarditis and urgent surgery in native and prosthetic valve endocarditis increased surgical mortality.

Mixomas cardíacos: correlaciÓn anatomoclínica

Introduction and objectives. Myxomas are the most common type of primary cardiac tumors. The aim of this study was to analyze the clinical forms of presentation of cardiac myxoma, the postoperative evolution, and the possibility of recurrence and tumoral embolism. Patients and method. From July 1992 to March 1999, 31 patients with myxoma were studied. Cell cycles (ploidy pattern of the tumoral DNA) were studied in 12 patients to evaluate the risk of recurrence and tumoral embolism. Results. The most frequent clinical manifestations were constitutional symptoms (74%), dyspnea (45%), and embolism (41%). Smaller-diameter myxomas correlated independently with tumoral embolism (45%). The inhospital mortality was 3.2%, no deaths were observed during follow-up (mean: 4.8 years). No patients had clinical or echocardiographic signs of tumoral recurrence. Patients with tumoral embolism (n = 8) were compared with patients without embolism (n = 4). Patients who suffered embolism had higher S phase > 7 and/or DNA index > 1.2 (4/4 patients [100%], p= 0.061) than patients without embolism (2/8 patients [25%]). Cytometry of the only recurrent tumor (second operation) revealed a diploid tumor with a significantly more frequent S phase (10%) than in sporadic myxomas (4.27 ± 2.32%, p = 0.039). Conclusions. Constitutional symptoms, dyspnea, and tumor embolism were the most frequent clinical manifestations. Clinical and anatomopathologic characteristics and the cell cycle were not significantly related to tumoral embolism, but there was a tendency toward a higher proportion of cells in S phase and a higher DNA index in tumors associated with embolism. The S phase was significantly more frequent in the only case of recurrent myxoma and could be a potential marker of recurrence.

Local thrombus as an isolated sign of traumatic aortic injury.

We report an unusual case of blunt traumatic aortic injury in which a mobile thrombus located at the isthmus was the only abnormality detected by transesophageal echocardiography. The case illustrates the high sensitivity of this diagnostic tool in aortic trauma and underscores the possibility of finding infrequent evidence of injury in subtle aortic lesions.

Las formas actuales de la endocarditis infecciosa

1123 La endocarditis infecciosa sigue siendo, a pesar del tiempo transcurrido (más de un siglo) desde sus primeras descripciones y de los avances realizados en su diagnóstico y tratamiento, una enfermedad muy grave, con elevadas tasas de complicaciones y mortalidad (que se sitúa en torno al 1520% o superiores en la mayoría de las series). Esta alta morbimortalidad puede estar relacionada con los cambios producidos en su etiopatogenia, con la aparición de nuevas formas distintas a la clásica endocarditis subaguda sobre válvula nativa. El presente libro, escrito por miembros de una única institución, el Instituto de Cardiología y Cirugía Cardiovascular de la Fundación Favaloro, en Buenos Aires (Argentina), intenta responder precisamente a estos cambios, tal como su propio título indica. En conjunto, se trata de una excelente revisión de la situación actual de la endocarditis infecciosa, a la que se aporta la experiencia personal de los autores. La presentación del libro es muy cuidada, con una excelente iconografía. En la introducción y en el primer capítulo se trata de la filosofía de la obra, comentando la evolución de la endocarditis infecciosa y los cambios producidos en la última década. Posteriormente, en los capítulos 2 a 5 se describen los aspectos clásicos en relación con la etiopatogenia, anatomía patológica y microbiología de la endocarditis. En el capítulo sobre el papel de la ecocardiografía se hace hincapié en los nuevos criterios diagnósticos, la importancia de la ecocardiografía transesofágica y el posible papel pronóstico de los hallazgos ecocardiográficos. En un corto capítulo, se habla después sobre un aspecto hoy bastante olvidado en el diagnóstico de la endocarditis, como es el de la posible localización de la infección y de la inflamación por distintas técnicas radioisotópicas, citándose las nuevas posibilidades futuras. En los capítulos siguientes se pasa revista a las distintas formas de la endocarditis infecciosa en la actualidad: endocarditis izquierdas nativas, endocarditis protésicas precoces y tardías, endocarditis en pacientes adictos a drogas por vía parenteral y endocarditis nosocomiales. Por último, en los capítulos finales se trata del diagnóstico, tratamiento antibiótico, profilaxis y tratamiento quirúrgico de la endocarditis infecciosa, dando unas pautas claras sobre las indicaciones de cada tipo de terapéutica. Para terminar, los autores presentan en el último capítulo varios casos clínicos que ilustran el espectro clínico y terapéutico de esta enfermedad. Se trata, por tanto, en mi opinión, de un libro interesante, homogéneo y bien estructurado sobre un tema poco conocido en general por los cardiólogos, y cuya lectura puede contribuir a incrementar la información y el interés por esta grave patología.

Manual debridement of the aortic valve in elderly patients with degenerative aortic stenosis

OBJECTIVE We prospectively analyzed the short- and long-term results of manual debridement of the aortic valve in elderly patients with severe degenerative aortic stenosis. METHODS Between September 1988 and January 1997, 103 patients aged 73.7 +/- 6 years with degenerative aortic stenosis underwent the manual debridement technique. All had symptoms (angina or dyspnea, or both). Peak systolic gradient was 89 +/- 28 mm Hg. Forty-one patients (39.8%) had associated coronary artery disease necessitating revascularization. RESULTS Follow-up time was 42 +/- 21 months (range 3-98 months). The Kaplan-Meier estimated survival at 98 months was 50% (95% CI: 30%-70%). In-hospital mortality was 5.8% (6 patients), and late mortality was 21% (21 patients). No predictors of in-hospital mortality or of late mortality were detected. Nonfatal postoperative complications appeared in 25 patients (24%). At 8 years, freedom from endocarditis was 98% (95% CI: 95%-100%) and freedom from thromboembolic events was 99% (95% CI: 96%-100%). No patient required long-term anticoagulation as a result of the procedure. Fourteen patients (14%) required reoperation for aortic insufficiency (n = 5), restenosis (n = 8), and mitral regurgitation (n = 1). The probability of reoperation at 98 months was 23% (95% CI: 12%-35%). CONCLUSION Manual aortic valve debridement has low rates of in-hospital mortality, perioperative complications, and thromboembolic and infectious events and it offers freedom from anticoagulation. However, the incidence of restenosis and reoperation is high in the long term. It may therefore be regarded as an alternative in aged patients with favorable valve anatomy (no distortion and calcium deposits only on the aortic surface of the cusps), especially in those with a small aortic anulus, associated coronary artery disease, and/or contraindication for anticoagulation.

Unusual “Polycystic” Appearance of a Right Atrial Angiosarcoma Described by Transesophageal Echocardiography

Angiosarcoma is the most common primary sarcoma of the heart and the most frequent location of the tumor is the right atrium. In the few published cases of right atrial angiosarcoma studied by transesophageal echocardiogaphy, the features described greatly differ from one to another. We describe the transesophageal images of a prolapsing mass type angiosarcoma with polycystic appearance previously misinterpreted as a right atrial myxoma in two consecutives transthoracic echocar‐diograms.

Seudoaneurisma de aorta ascendente

Varon de 67 anos, hipertenso, diabetico, con historia de reemplazo valvular aortico con protesis mecanica en 1991 por estenosis valvular, complicada en el postoperatorio inmediato con diseccion aortica tipo A que determina cirugia de urgencia. Se realiza reemplazo de aorta ascendente con tubo protesico (preservando la raiz aortica y la protesis valvular), con buena evolucion postoperatoria. En enero de 1999 presenta de forma subita disnea y dolor retrosternal irradiado a dorso. En el momento de la consulta el paciente se encuentra palido, sudoroso e hipotenso. El electrocardiograma no revela alteraciones agudas. La radiografia de torax demuestra un significativo ensanchamiento mediastinico. Sin disponer de los detalles de la cirugia previa y ante la sospecha de diseccion aortica tipo A, se decide