Diego Ugalde

Nacimiento anómalo de las arterias coronarias en 10.000 pacientes adultos sometidos a coronariografía

Background: Between 0.3 and 1.3% of coronary arteries, have anomalous origins. Circumflex artery has the higher frequency of anomalies. Aim: To study the frequency of congenital anomalous origins of coronary arteries among adult patients subjected to a coronary angiography. Material and Methods: Analysis of reports of 10,000 coronary angiographies performed in a clinical hospital. Patients with congenital heart disease were excluded. Results: One hundred twenty nine patients (1.3%), aged 59 ± 12years (70% males) had congenital anomalies in the origin of coronary arteries. The most common anomaly was the origin of right coronary artery from the left coronary sinus in 75%, followed from the origin of circumflex artery from the right side in 20%o. No association between origin anomalies and atherosclerosis or aortic valve disease, was observed. Conclusions: In this series of patients, origin anomalies of coronary arteries were not associated with aortic valve disease or atherosclerosis, differing from other published reports. Right coronary artery had the highest frequency of anomalies.

High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock

Como Cornejo et al. observaram, essas duas tecnicas sao desafiadoras e necessitam de um ava-liacao caso a caso para tomada de decisao. Devem ser considerados os possiveis efeitos adversos dessas tecnicas. Uma metanalise mostra que “nao ha um efeito benefico global claro” quando se compara a hemofiltracao de alto volume com a hemofiltracao com volume padrao.We would like to discuss the publication “High-volume hemofiltration and prone ventilation”.(1) Cornejo et al. reported the use of the combination of these two novel approaches for the management of subarachnoid hemorrhage that is complicated by severe acute respiratory distress syndrome.(1) As Cornejo et al. noted, these two techniques are very challenging and require case by case decision making. There must be consideration of the possible adverse effects of these techniques. A meta-analysis shows that there is “no clear overall beneficial effect” when high-volume hemofiltration is compared to standard volume hemofiltration.(2) Some reports mention the adjustment of cytokine biological processes as the possible responsible factor, whereas other reports do not agree with that hypothesis.(2) In the present case report by Cornejo et al., the reason for the occurrence of septic shock remains unclear. Based on the patient’s available history, it seems that there is no laboratory confirmation of sepsis. Additionally, there is no evidence of cytokine biological process adjustment reported in the present article. In general, due to the uncertainties about the exact biological effect of high-volume hemofiltration, the beneficial effects of this procedure remain unconfirmed in septic shock.(3) Regarding prone positioning, the complication and side effect of the procedure can still be observed.(4) Cardiac arrest immediately after prone positioning is also reported.(5) In the present case report, the use of prone positioning might be valid, and the success of cardiac monitoring is established. Interestingly, 72 hours of prone positioning were required for adjustment of the pressure. This long period might be sufficient for self-adjustment of the patient’s intracranial pressure, due to the neurological improvement after manipulation or other additional procedures for the management of pressure, without the need of a special positioning procedure. The improvement of the patient might be due to the successful control of the neurological problem and might not be related to the use of high-volume hemofiltration plus prone positioning.

Terapia de reperfusión en infarto agudo al miocardio: Comparación entre trombolisis endovenosa y angioplastía coronaria

BACKGROUND Primary angioplasty is superior to intravenous thrombolysis as reperfusion therapy for acute myocardial infarction. AIM To compare the results of available reperfusion strategies for initial management of acute myocardial infarction during hospitalization and 5 years follow up. PATIENTS AND METHODS Historical cohort study from a prospective registry of patients admitted with acute myocardial infarction to our center. Patients treated with primary angioplasty were identified and were then matched by age, sex and date of event with patients treated with throm-bolysis. The clinical outcomes were compared including hospitalization and 5-years follow-up. RESULTS From March 1993 to August 2001, 98 patients were treated with primary angioplasty and matched with 98 thrombolyzed patients. The groups were comparable. Compared to thrombolysis, angioplasty had a higher success rate (68 and 91% respectively), resulted in less complications and reduced mortality (11 and 2% respectively), required less revascularization procedures and shorter hospital stay (17 and 13 days, respectively). During the follow-up of survivors, no differences in events or additional mortality were detected at 1 or 5 years. CONCLUSIONS Primary angioplasty is superior as treatment in terms of achieving success and reducing mortality during hospitalization. Evolution after hospitalization is independent of initial therapy.

Hemofiltração de alto volume e ventilação em posição prona em hemorragia subaracnóidea complicada por grave síndrome do desconforto respiratório agudo e choque séptico refratário.

Relatamos o tratamento bem-suce- dido de dois pacientes com hemorragia subaracnoidea complicada com grave falencia respiratoria e choque septico refratario, utilizando, simultaneamente, ventilacao em posicao prona e hemofil - tracao de alto volume. Esses tratamentos de resgate permitiram que os pacientes superassem a grave situacao sem com- plicacoes associadas ou efeitos deleterios na pressao intracraniana e de perfusao cerebral. A ventilacao em posicao pro- na e, hoje, um tratamento aceito para sindrome de desconforto respiratorio agudo grave, e a hemofiltracao de alto volume e um suporte hemodinâmico nao convencional, que tem diversosWe report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team.

Angioplastía primaria en infarto agudo al miocardio en arteria coronaria derecha con origen anómalo: Caso clínico

Anomalous origin of coronary arteries is a rare anatomical defect and its association with acute myocardial infarction is unusual. We report a 58-year-old male with ST-Segment elevation. Myocardial infarction of the inferior wall caused by a total occlusion on the proximal third of an anomalous right coronary artery, that was effectively treated with primary angioplasty with stent placement. The patient had a favorable outcome and is asymptomatic after five years of follow up.

Transthoracic cardiac ultrasound in prone position: a technique variation description

Cardiac ultrasound as the primary method for advanced hemodynamic monitoring is a paramount skill in the intensive care unit (ICU). It is particularly relevant to evaluate the right ventricle in acute respiratory distress syndrome (ARDS). Therapies to improve outcomes in ARDS include low tidal volume ventilation, neuromuscular blockade, restricted fluid administration, and prone position ventilation (PPV). The last of these is considered to impede transthoracic cardiac ultrasound. In our ICU, we have no acute access to a transesophageal probe; thus, only the transthoracic approach is usually available. Here we describe the local technique to perform cardiac ultrasound during PPV. We use the “swimmer position” to perform PPV, periodically changing side to prevent ulcers. We use PPV continuously for at least 48 h. In the left prone position, left shoulder elevation with a pillow forms a space to put the transducer. To keep the skills as used in the usual supine position, left-handed operators stand at the left of the patient facing his feet as in Fig. 1a. Applying the same principle, a right-handed operator might face the head instead. PPV ultrasound affords all apical views and related measures, but no other acoustic window (Fig. 1b, c). The right ventricle is evaluated as usual.

Fístula coronaria gigante. Presentación clínica, caracterización angiográfica, tratamiento y seguimiento a largo plazo: Caso clínico

Coronary artery fistulae are abnormal connections between a coronary artery and any cardiac chamber or other vessels. Most of them have a congenital origin. We report a 60 years old woman referring a history of progressive dyspnea and orthopnea during the last year. A continuous heart murmur was audible in the third and fourth intercostal spaces at the left sternal border. Electrocardiogram was normal and echocardiography showed mild dilation of right cavities and an image suggesting a dilated right coronary artery with flow to right atrium. Coronary angiography was performed, showing a normal left coronary artery and a very large, tortuous right coronary artery with an extensive communication to coronary venous sinus. Surgical treatment was decided and was performed without incidents. The patient is well after five years of follow up.

Infarto agudo al miocardio en el adulto mayor: Características clínicas, evolución hospitalaria y a 5 años plazo

Background: Among aged patients, acute myocardial infarction has more complications and there is a tendency to underuse proven treatments. Aim: To report the features of acute myocardial infarction among aged patients. Material and methods: Analysis of a registry of patients with acute myocardial infarction admitted to a coronary unit. For the purposes of analysis, patients aged 65 years or more were selected. Follow up was made consulting medical records, calling patients by telephone or consulting death records at the National Identification Service. Results: A total of 1358 patients were admitted in the study period with a diagnosis of acute myocardial infarction and 580 (43%) were aged 65 years or more. On admission, this age group had a higher frequency of hemodynamic instability and anterior wall infarctions. Reperfusion therapy and beta blockers were used less commonly in this group. Hospital mortality among patients younger or older than 65 year was 8 and 25%, respectively (p< 0.01). Among aged patients, five years mortality was 33%. Conclusions: Among aged patients, acute myocardial infarction has a higher risk profile on admission, is usually undertreated and had a higher mortality than in younger subjects.