Dolores Mesa

Transcatheter occlusion of complex atrial septal defects

Percutaneous device occlusion of secundum atrial septal defects (ASDs) is becoming an accepted alternative to surgical closure. This method allows us to evaluate patients with complex conditions for treatment. From a total of 70 patients with ASD evaluated for percutaneous closure, we selected for analysis 28 who had complex conditions. The mean age was 36 ± 23 yr (range, 4–72). Six had heart failure, and of these six, three had atrial fibrillation. At cardiac catheterization, the pulmonary pressure was 47 ± 24 mm Hg, and the QP/QS was 1.7 ± 0.4; two patients had bidirectional shunt and systemic pulmonary pressure. Two patients received a buttoned device and 26 an Amplatzer septal occluder. The groups of patients with complex conditions were separated into the following groups. Group I (n = 4) underwent combined treatment of associated anomalies. Two patients had pulmonary stenosis, one had mitral stenosis, and one had an aortic root–left atrium fistula. They were treated in or during with the same procedure by combined transcatheter techniques (balloon valvuloplasty and fistula occlusion) before ASD occlusion. Group II (n = 9) had multiple defects (cribiform or two separate holes). They were treated with a single device in five instances and with two separate devices in four cases. Group III (n = 14) had large (32 ± 3 mm) single defects. Nine of them underwent successful implantation using a device 33 ± 3 mm in diameter; in the remaining five patients the device was removed because of instability. Group IV (n = 3) had residual defects after previous partial device occlusion. All three defects were successfully occluded with a second device. No movement or interference with the first device was observed. Group V (n = 6) had severe pulmonary hypertension (86 ± 16 mm Hg). Immediately after ASD occlusion we observed significant relief in these patients (67 ± 14 mm Hg; P < 0.01). There were no major complications; all 23 patients with successful implants were discharged without symptoms 2–7 days later; one patient with atrial fibrillation recovered sinus rhythm. The follow‐up (8 ± 5 mo) Doppler echo study showed complete ASD occlusion in 22 patients and a peak pulmonary pressure of 30 ± 14 mm Hg. We conclude that transcatheter occlusion of ASDs is an effective and safe treatment for patients with complex anatomic or physiopathologic conditions, as evaluated by short‐term follow‐up. Cathet. Cardiovasc. Intervent. 51:33–41, 2000.

Características clínicas y pronóstico a medio plazo de la insuficiencia cardíaca con función sistólica conservada. ¿Es diferente de la insuficiencia cardíaca sistólica?

Objetivos Analizar la prevalencia, las caracteristicas clinicas y el pronostico a medio plazo de los pacientes con insuficiencia cardiaca y funcion sistolica conservada, y compararlos con los que presentan disfuncion ventricular. Pacientes y metodo Se incluyo a un total de 153 pacientes, 62 con funcion sistolica conservada (fraccion de eyeccion ventricular izquierda ≥ 45%) y 91 con disfuncion ventricular (fraccion de eyeccion Resultados Las edades medias fueron similares (66 ± 10 frente a 65 ± 10 anos; p = 0,54). La proporcion de mujeres fue mayor entre los pacientes con funcion sistolica conservada (53 frente a 28%; p Conclusiones Una importante proporcion de pacientes con insuficiencia cardiaca presentan una funcion ventricular sistolica conservada. Aunque las caracteristicas clinicas de estos pacientes son distintas de las de aquellos con disfuncion ventricular sistolica, el pronostico a medio plazo fue similar.

Oral Anticoagulation in Nonvalvular Atrial Fibrillation in Clinical Practice: Impact of CHADS2 Score on Outcome

Objectives: CHADS2 score predicts embolic risk in patients with nonvalvular atrial fibrillation (NVAF), but also bleeding risk in patients receiving oral anticoagulation (OAC). Our objective is to analyze the effectiveness and safety of OAC in patients with NVAF in daily clinical practice, according to embolic risk evaluated by means of CHADS2 score. Methods: All consecutive outpatients with permanent NVAF seen at 2 cardiology clinics were prospectively followed for embolic events (transient ischemic attack, ischemic stroke, peripheral embolism) and severe bleedings. OAC was prescribed according to the recommendations of scientific associations. CHADS2 score was obtained for each patient. Results: From February 1, 2000 to July 31, 2003, 796 outpatients fulfilled the inclusion criteria. OAC was prescribed to 564 (71%) patients. After 2.4 ± 1.9 years of follow-up, the embolic event rates (per 100 patient-years) for each stratum of the CHADS2 score for patients with/without OAC were: 1/4.1, p = 0.23 (CHADS2 = 0); 0.6/7.1, p = 0.0018 (CHADS2 = 1); 0.5/5.1, p = 0.0014 (CHADS2 = 2); 2.4/12.5, p = 0.0017 (CHADS2 = 3) and 2.9/20, p = 0.013 (CHADS2 ≧4). The severe bleeding rates for the same CHADS2 score strata were 3/0.8, 0.8/0.7, 1.3/0.7, 0.4/0, and 2.9/5 in patients with/without OAC (n.s.). Conclusion: OAC is effective and safe in daily clinical practice in patients with NVAF and CHADS2 score ≧1.

Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF): A randomised study

OBJECTIVES To analyse the effect of the early coadministration of ivabradine and beta-blockers (intervention group) versus beta-blockers alone (control group) in patients hospitalised with heart failure and reduced left ventricular ejection fraction (HFrEF). METHODS A comparative, randomised study was performed to compare the treatment strategies of beta-blockers alone versus ivabradine and beta-blockers starting 24hours after hospital admission, for acute HF in patients with an left ventricular ejection fraction (EF)<40%, sinus rhythm, and a heart rate (HR)>70bpm. RESULTS A total of 71 patients were examined, 33 in the intervention group and 38 in the control group. No differences were observed with respect to their baseline characteristics or standard treatment at discharge. HR at 28days (64.3±7.5 vs. 70.3±9.3bpm, p=0.01) and at 4months (60.6±7.5 vs. 67.8±8bpm, p=0.004) after discharge were significantly lower in the intervention group. Significant differences were found with respect to the EF and brain natriuretic peptide levels at 4months. No differences in clinical events (rehospitalisation/death) were reported at 4months. No severe side effects attributable to the early administration of ivabradine were observed. CONCLUSIONS The early coadministration of ivabradine and beta-blockers during hospital admission for acute HFrEF is feasible and safe, and it produces a significant decrease in HR at 28days and at 4months after hospital discharge. It also seemed to improve systolic function and functional and clinical parameters of HF patients at short-term.

Factores de riesgo asociados a endocarditis sin cardiopatía predisponente

La patogenia de la endocarditis infecciosa (EI) ha cambiado en las ultimas decadas, siendo cada vez mayor el numero de casos sin cardiopatia predisponente. El objetivo de este trabajo es conocer las caracteristicas de los pacientes no drogadictos afectados de EI sin cardiopatia predisponente e identificar los posibles factores de riesgo para la infeccion. De 196 casos de EI, 49 (25%) ocurrieron en pacientes sin cardiopatia predisponente. Se identifico en la mayoria (26 casos) un factor de riesgo para la infeccion, predominando las enfermedades digestivas (6 casos), hemodialisis (6 casos) y cateteres venosos centrales (4 casos). La infeccion se localizo con mayor frecuencia en las valvulas derechas (29 frente a 6%; p

Functional Recovery Following Intracoronary Infusion of Autologous Mononuclear Bone Marrow Cells in Patients With Chronic Anterior Myocardial Infarction and Severely Depressed Ventricular Function

INTRODUCTION AND OBJECTIVES Studies have shown that intracoronary infusion of mononuclear bone marrow cells improves ventricular function in patients with acute myocardial infarction. However, less information is available about the use of this therapy during the chronic phase of a myocardial infarction. This study involved an analysis of the clinical, echocardiographic and angiographic changes observed in 19 patients with a revascularized chronic anterior myocardial infarction and depressed ventricular function who were treated by cell therapy. METHODS A series of patients were monitored during treatment and 6 months and 1 year after treatment. Autologous bone marrow was obtained by needle aspiration of the iliac crest and mononuclear cells were isolated by density-gradient centrifugation. An in vitro biological study of a sample of the infused cells was performed using fluorocytometry, phenotype marking and an analysis of the chemotactic properties of the cells. RESULTS Six months and 1 year after cell therapy, a modest improvement was observed in clinical status and ventricular function, which was most pronounced in the group of patients who responded. Characteristically, these patients were revascularized close to the time of cell therapy. There was an inverse relationship between functional recovery and biological parameters that reflected a state conducive to cell migration. CONCLUSIONS The intracoronary infusion of mononuclear bone marrow cells into patients with chronic anterior myocardial infarction appeared to result in a modest clinical and functional improvement after 6 months which was sustained up to 1 year after treatment.

Recuperación funcional tras infusión intracoronaria de células mononucleadas de médula ósea autóloga en pacientes con infarto crónico anterior y depresión severa de la función ventricular

Introduccion y objetivos Diferentes estudios han demostrado que la infusion intracoronaria de celulas mononucleadas de la medula osea en pacientes con infarto agudo de miocardio mejora la funcion ventricular. Sin embargo, existe menos informacion sobre esta terapia en la fase cronica de un infarto. Este estudio analiza los cambios clinicos, ecocardiograficos y angiograficos observados en 19 pacientes con infarto anterior cronico revascularizado y funcion ventricular deprimida que fueron tratados con terapia celular. Metodos Se estudio a los pacientes de forma seriada durante la fase del tratamiento, a los 6 meses y al ano. La medula osea autologa fue extraida mediante puncion aspirativa sobre cresta iliaca, y las celulas mononucleadas se aislaron por centrifugacion en gradiente de densidad. Se efectuo un estudio biologico in vitro de una muestra de las celulas infundidas, para citofluorometria, marcacion fenotipica y analisis de la capacidad quimiotactica de las celulas infundidas. Resultados A los 6 meses y al ano de la terapia celular se observo una ligera mejoria clinica y de la funcion ventricular, mas acusada en un grupo de pacientes respondedores. Estos se caracterizaban por haberse sometido a revascularizacion de forma mas cercana a la terapia celular. Se observo una relacion inversa entre los parametros funcionales y los biologicos que traducen un estado de actividad proclive a la migracion. Conclusiones La infusion intracoronaria de celulas mononucleares de la medula osea en pacientes con infarto anterior cronico parece producir una ligera mejoria clinica y funcional a los 6 meses que se mantiene al ano del tratamiento.

Long-Term Outcome of Patients With Isolated Thin Discrete Subaortic Stenosis Treated by Balloon Dilation A 25-Year Study

Background— Transluminal balloon tearing of the membrane in a thin discrete subaortic stenosis is an alternative to membrane surgical resection. However, the long-term outcome of patients with isolated thin discrete subaortic stenosis treated by transluminal balloon tearing remains unknown. Methods and Results— This 25-year study describes findings from 76 patients with isolated thin discrete subaortic stenosis who underwent percutaneous transluminal balloon tearing of the membrane and were followed up for a mean period of 16±6 years. The age at presentation had a wide range (2–67 years). The mean age at treatment was 19±16 years. Immediately after treatment, the subvalvular gradient decreased from 70±27 to 18±12 mm Hg (P<0.001). No significant postprocedural aortic regurgitation was observed. After a mean follow-up time of 16±6 years, 11 patients (15%) developed restenosis, 3 patients (4%) progressed to muscular obstructive disease, and 1 patient (1.3%) developed a new distant obstructive membrane. Twelve patients (16%) were redilated at a mean of 5±3 years after their first treatment, and 4 patients (5%) underwent surgery at a mean of 3±2 years after their first treatment. Fifty-eight patients (77%) remained alive and free of redilation or surgery at follow-up. Larger annulus diameter and thinner membranes were independent factors associated with better long-term results. Conclusions— Most patients (77%) with isolated thin discrete subaortic stenosis treated with transluminal balloon tearing of the membrane had sustained relief at subsequent follow-ups without restenosis, the need for surgery, progression to muscular obstructive disease, or an increase in the degree of aortic regurgitation.

Reemplazamiento valvular aórtico con autoinjerto pulmonar ( operación de Ross) , en pacientes adultos y pediátricos. Estudio preliminar

Introduccion y objetivos. El reemplazamiento valvular aortico con autoinjerto pulmonar (opera-cion de Ross) se ha llegado a establecer como uno de los mejores metodos quirurgicos para el reemplazamiento de la valvula aortica en determinados grupos de pacientes. Aunque fue descrita por Ross en 1967, han tenido que pasar muchos anos para que, a la vista de la experiencia acumulada, las indicaciones se hayan extendido, incluso, a pacientes recien nacidos y pediatricos con formas complejas del tracto de salida de ventriculo izquierdo. El objetivo de nuestro trabajo es aportar la experiencia y resultados preliminares en un grupo de quince pacientes (adultos y pediatricos), intervenidos con esa tecnica. Material y metodos. En 6 pacientes la etiologia fue congenita y en 9 adquirida. Dos de ellos inter-venidos previamente con circulacion extracorporea, por obstruccion severa del tracto de salida de ventriculo izquierdo. Resultados. En todos ellos, se realizo procedimiento de Ross con insercion del autoinjerto pulmonar en forma de raiz total en posicion aortica, con reimplantacion de coronaria. La media de dia-metro de los homoinjertos pulmonares criopreservados fue de 26,1 ± 4 mm (19-35). En todos los casos se hizo estudio ecocardiografico transesofagico intraoperatorio y postoperatorio (1-2 meses). Solo un caso presento insuficiencia leve del autoinjerto pulmonar y ningun caso tuvo gradiente transaortico o transpulmonar postoperatorio. Un paciente fue reintervenido por hemorragia precozmente, ningun paciente presento complicaciones significativas y no hubo ningun caso de mortalidad hospitalaria, ni en el seguimiento a corto plazo (41-155 dias). Todos los pacientes estan libres de tratamiento anticoagulante en grado funcional I de la New York Heart Association. Conclusiones. En los resultados ecocardiograficos preliminares a corto plazo de nuestra serie, que incluye pacientes adultos y pediatricos, se observa un excelente comportamiento hemodinamico del autoinjerto pulmonar.

Características clínicas y pronóstico de la endocarditis infecciosa en la mujer

Introduccion y objetivos El pronostico de la endocarditis infecciosa en la mujer ha sido poco estudiado. El objetivo del presente estudio es analizar las caracteristicas clinicas y el pronostico de las mujeres con endocarditis infecciosa atendidas en nuestra institucion en los ultimos 20 anos. Metodos Analisis comparativo de 288 pacientes con endocarditis infecciosa desde 1987 hasta 2006. De ellos, 104 (36%) eran mujeres. Resultados La media de edad fue similar en ambos grupos (50 ± 18 anos los varones y 52 ± 21 las mujeres), asi como la incidencia de endocarditis sobre protesis precoz y tardia (endocarditis protesica precoz: varones, 42%; mujeres, 49%). La infeccion se localizo con mayor frecuencia en la valvula mitral en las mujeres (el 54 frente al 39%) y en la valvula aortica en los varones (el 50 frente al 29%; p Conclusiones Las caracteristicas clinicas de la endocarditis infecciosa son similares en varones y mujeres; sin embargo, las mujeres se operan con menor frecuencia a pesar de una tasa similar de complicaciones severas durante la fase activa.