Enric Esplugas

Insuficiencia mitral funcional. Fisiopatología e impacto del tratamiento médico y de las técnicas quirúrgicas de reducción ventricular izquierda

La insuficiencia mitral funcional es un hallazgo frecuente en la disfuncion ventricular izquierda. Su presencia es un marcador de mal pronostico en pacientes con miocardiopatia isquemica o idiopatica. El mecanismo responsable de este fenomeno es un balance alterado entre las fuerzas de tension y las de coaptacion que actuan sobre las valvas mitrales en el corazon con insuficiencia. Las fuerzas de tension representan un estiramiento anomalo sobre los velos mitrales originado por el desplazamiento de los puntos de anclaje de la valvula mitral. Dicho desplazamiento se debe al incremento en la esfericidad de la cavidad ventricular izquierda asociado a la disfuncion ventricular sistolica. Por otro lado, las fuerzas de coaptacion son debiles e incapaces de contrarrestar la tension anormal que restringe su cierre y conduce a la regurgitacion. Los farmacos vasodilatadores e inotropicos son efectivos en el manejo de la insuficiencia mitral funcional. Aunque la ventriculectomia izquierda parcial o intervencion de Batista aun se considera una tecnica en investigacion, este nuevo procedimiento parece ofrecer un optimo control de la insuficiencia mitral funcional, asi como una mejoria de la capacidad funcional y de la supervivencia de ciertos pacientes con insuficiencia cardiaca.

Use of Impella Recover LP 2.5 in elective high risk percutaneous coronary intervention

We describe a single-center experience in using the Impella Recover LP 2.5 in the setting of high-risk elective percutaneous coronary interventions. This device is placed percutaneously to support cardiac output and has a better profile than other left ventricular assist devices. Our study shows that the use of the Impella Recover LP 2.5 device is feasible, has an overall favorable safety profile, and may help prevent periprocedural and short-term complications derived from high-risk procedures.

Infarto agudo de miocardio tras terapia electroconvulsiva

El infarto de miocardio es un cuadro infrecuente dentro de las complicaciones de la terapia electro-convulsiva. Por ello, a pesar de la existencia en la bibliografia psiquiatrica de algunos estudios sobre este tema, los conocimientos al respecto de la mayoria de cardiologos son escasos. Presentamos el caso de una paciente que, minutos despues de la aplicacion de una sesion de terapia electroconvul-siva, presento un infarto agudo de miocardio. Posteriormente, realizamos revision de la bibliografia en relacion con la incidencia, fisiologia, utilizacion preventiva de diversos farmacos e indicacion o no de trombolisis sistemica del infarto agudo de miocardio posterapia electroconvulsiva.

Programa de Prevención Secundaria de la Arteriosclerosis de un hospital universitario. Resultados y factores predictivos del curso clínico

Fundamento Y Objetivo En un alto porcentaje de pacientes con enfermedad coronaria (EC) no se alcanzan los objetivos en el tratamiento de las dislipemias. Describimos la metodologia y los resultados del Programa de Prevencion Secundaria del Hospital Universitario de Bellvitge (PPSHB), cuyo principal objetivo es prevenir las recurrencias isquemicas mediante el control de los factores aterogenicos. Pacientes y metodo Desde enero de 1992 a diciembre de 1996, 882 pacientes con EC fueron incluidos en el PPSHB y fueron visitados en la Unidad de Lipidos y Arteriosclerosis en, al menos, dos ocasiones durante un periodo medio (DE) de 10,4 (3,8) meses. En 753 pacientes se obtuvieron los datos sobre su evolucion clinica mediante un cuestionario telefonico y revision de las historias clinicas. Resultados Durante el periodo de seguimiento en la Unidad de Lipidos y Arteriosclerosis el 71,9% de los pacientes alcanzaron los objetivos terapeuticos o mejoraron un 15% o mas el colesterol unido a lipoproteinas de baja densidad (cLDL). Este resultado se observo en el 83,6% de los pacientes para el colesterol unido a lipoproteinas de alta densidad (cHDL), el 78,7% para los trigliceridos y el 83,6% para el cociente cHDL/cLDL. En este periodo, el porcentaje de pacientes en tratamiento con farmacos hipolipemiantes aumento del 28 al 69%. Durante el periodo de seguimiento de 33,7 (15,9) meses fallecieron, por cualquier causa, 41 pacientes (5,4%) y el tiempo medio de supervivencia fue de 20 (13,4) meses. La hospitalizacion por enfermedad cardiovascular ocurrio en 113 pacientes (15%), con un tiempo medio de seguimiento hasta el primer ingreso de 18,4 (14,2) meses. El hecho de no alcanzar el objetivo terapeutico del cociente cHDL/cLDL (cHDL/cLDL igual o superior a 0,27 o un aumento del 15% o superior) fue el principal factor predictivo de un curso clinico desfavorable, con una odds ratio de 2,1 (intervalo de confianza del 95%, 1,1-4,03). Conclusiones Una estrategia sistematica de prevencion secundaria de la arteriosclerosis puede contribuir a lograr un control adecuado de las dislipemias en la mayoria de los pacientes con EC. En estos pacientes, alcanzar el objetivo terapeutico del cHDL/cLDL se asocia a una disminucion superior al 50% del riesgo de reingresar por enfermedad cardiovascular o de fallecer por cualquier causa.

Mejoría de la función endotelial al reducir las concentraciones lipídicas en pacientes con hipercolesterolemia y arterias coronarias normales

Introduccion y objetivos En pacientes con factores de riesgo coronario se ha documentado la presencia de disfuncion endotelial en las arterias epicardicas. El proposito del estudio fue determinar si la disfuncion endotelial en pacientes hipercolesterolemicos y coronarias angiograficamente normales mejoraba despues de reducir y mantener normalizadas las concentraciones lipidicas. Pacientes y metodo En 10 pacientes con hipercolesterolemia y coronarias sin lesiones angiograficas, la vasomotilidad dependiente del endotelio se estudio mediante la administracion intracoronaria de acetilcolina en la arteria descendente anterior. Los cambios vasomotores fueron analizados mediante angiografia cuantitativa. Cinco pacientes sin factores de riesgo y con coronarias normales formaron el grupo control. Los pacientes hipercolesterolemicos fueron tratados con lovastatina y dieta, reevaluandose la funcion endotelial 24 ± 4 meses despues. Resultados En el estudio inicial los pacientes hipercolesterolemicos presentaron una respuesta vasoconstrictora a dosis crecientes de acetilcolina (10–6 M, 10–5 M y 10–4 M) indicativa de disfuncion endotelial (grupo estudio: –0,3 ± 10%, –6 ± 4% y –18 ± 10%, frente al grupo control: –0,6 ± 6%, –2 ± 6% y 3 ± 6%; p Conclusion En pacientes con hipercolesterolemia y coronarias angiograficamente normales en quienes se documenta disfuncion endotelial, la reduccion y normalizacion de las concentraciones lipidicas condiciona una mejoria de dicha disfuncion endotelial.

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation☆

BACKGROUND Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.

Seguimiento a largo plazo tras el tratamiento percutáneo del tronco coronario izquierdo no protegido en pacientes de alto riesgo no aptos para cirugía de revascularización

INTRODUCTION AND OBJECTIVES Percutaneous coronary intervention is recommended in patients with unprotected left main stenosis non suitable for coronary artery bypass graft. Long-term follow-up of those patients remains uncertain. METHODS All patients with de novo unprotected left main stenosis treated with stent implantation were consecutively enrolled. Percutaneous coronary intervention was indicated according to the standards of care, taking into account clinical and anatomical conditions unfavorable for coronary artery bypass graft. The primary end point was the occurrence of major adverse cardiac events, a composite of death, nonfatal acute myocardial infarction, or target lesion revascularization. RESULTS Of 226 consecutive patients included, 202 (89.4%) were treated with drug-eluting stents. Mean age was 72.1 years, 41.1% had renal dysfunction, and mean Syntax score and EuroSCORE were 28.9 and 7.4, respectively. Angiographic and procedural success was achieved in 99.6% and 92.9% of patients. At 3 years, the rates of major adverse cardiac events, death, nonfatal acute myocardial infarction and target lesion revascularization were 36.2%, 25.2%, 8.4%, 8.0%, respectively. Target lesion revascularization was more frequently observed when ≥ 2 stents were implanted rather than a single stent (18.5% vs 5.8%, P=.03); and with bare metal stents rather than drug-eluting stents (13.0% vs 7.9%, P=.24). Definite stent thrombosis was observed in 2 patients (0.9%) and probable stent thrombosis in 7 (3.1%). Female sex, impaired left ventricular function, and use of bare metal stents were significantly related with all-cause mortality. CONCLUSIONS High-risk patients with unprotected left main stenosis treated with percutaneous coronary intervention presented with a high rate of major adverse cardiac events at long-term follow-up. Female sex, impaired left ventricular function, and use of bare metal stents were predictors of poor prognosis.

Uso de amiodarona oral como tratamiento crónico en un paciente con hepatitis fulminante previa por amiodarona intravenosa

La hepatitis aguda toxica secundaria a amiodarona intravenosa es un cuadro infrecuente con escasas apariciones en la bibliografia medica. En alguna ocasion se ha postulado su relacion con el vehiculo del preparado intravenoso y no con el principio activo. Presentamos a un paciente con hepatitis fulminante y encefalopatia hepatica grave tras la administracion de amiodarona intravenosa. Tambien presentamos la evolucion clinica posterior del paciente tras la reintroduccion de amiodarona por via oral. Finalmente, realizamos una revision de la bibliografia asociada a este caso.

Tratamiento de la reestenosis intra-stent. Situación actual y perspectivas futuras

In-stent restenosis is an increasing problem due to the frequent use of coronary stent as a form of percutaneous revascularization. The global incidence is near to 28%, and it is well document that a neointimal hyperplasia is its principal mechanism. The most commonly related factors for its appearance are diabetes mellitus, a longer length of the original lesion, a smaller diameter of the reference vessel, the left anterior descending artery location and a smaller luminal diameter at the end of the procedure. Due to a different long term evolution in-stent restenosis has been classified as focal or diffuse, according to the length of the restenotic lesion (focal or = 10 mm). Some strategies have been proven for its treatment, but no randomized-controlled trials have been published comparing these different treatments. In focal in-stent restenosis the practice of a conventional balloon angioplasty is associated with high initial clinical success with a favourable long term evolution (target lesion revascularization between 11-15%). But on the contrary, in diffuse in-stent restenosis, in spite of a high initial success rate, an elevated target lesion revascularization has been detected at the follow-up (up to 43%). Other proved such as atherectomy or excimer laser are associated with a significant procedural non-Q-wave infarction (near to 9%) and a long term target lesion revascularization during follow-up (23-31%). The implantation of an additional stent has been performed with low procedural complications and with a long term target lesion revascularization near to 27%. Patients treated with intracoronary radiation as a complementary technique seem to have a better long term evolution than those having had the other strategies alone. In conclusion, in-stent-restenosis is a new and progressively more frequent problem, requiring complex treatment and of which as been established. Comparative controlled studies need to be performed in order to determine the best treatment for this new entity.

Elevated troponin I levels in patients with acute coronary syndrome without ST elevation are associated with increased complexity of the culprit lesion

INTRODUCTION The prognosis in patients with acute coronary syndrome without persistent ST segment elevation (NSTEACS) differs depending on cardiac troponin levels. Clinical practice guidelines published by the Spanish Society of Cardiology and the ACC/AHA consider patients with NSTEACS and markedly elevated troponin levels as high risk patients. The aim of this study was to identify factors related to markedly elevated troponin I levels in NSTEACS. PATIENTS AND METHOD We measured troponin I levels in 219 consecutive patients with NSTEACS and normal CK-MB values, and identified 2 groups: patients with markedly elevated troponin levels (more than 10-fold the normal upper limit), and patients with normal or slightly elevated troponin levels (less than a 10-fold increase above the normal limit). We also analyzed clinical and angiographic variables. Logistic regression was used to calculate age- and sex-adjusted associations for the main variables. RESULTS Forty-one patients (19%) had markedly elevated troponin levels, and 178 (81%) showed normal or slightly elevated troponin I levels. Patients with markedly elevated levels had more frequently prolonged angina, class IIb angina, more severe ECG changes, a higher number of diseased vessels on coronary angiography, and greater severity of the culprit lesion. The culprit stenosis in these patients was more often characterized as ulcerated, showing visible thrombus, and excentric, bifurcated and irregular. Class IIIb angina (odds ratio [OR] = 3.1; CI 95%, 1.1-8.6), bifurcation (OR=6.04; CI 95%, 2.5-14.3), ulceration (OR=3.2; CI 95%, 1.07-9.7) and visible thrombus (OR=2.7; CI 95%, 1.1-6.3) in the culprit lesion were predictive factors associated with markedly elevated levels of troponin I independently of age or sex. CONCLUSIONS Markedly elevated troponin I levels in patients with NSTEACS are associated with a more severe clinical presentation and increased complexity of the culprit lesion on coronary angiography.