Esteban Escolar

Left Main Coronary Artery Acute Thrombosis Related to Energy Drink Intake

A 24-year-old previously healthy black man presented the emergency department with a 10-hour history of nausea, multiple episodes of emesis, palpitations, and severe retrosternal chest pain, described as constant pressure. His symptoms started 1 or 2 hours after he had 3 drinks of vodka mixed with an energy drink at a local party. He used marijuana in the week before but denied cocaine or other recreational drug use. Two of his friends who shared the drinks had similar symptoms but without chest pain. There was no family history of premature coronary artery disease. The patient smokes no more than 5 cigarettes weekly.nnAt admission, his vital signs were blood pressure 138/94 mm Hg, pulse 63 bpm, breathing rate 18 respirations per minute, temperature 36°C, and 99% oxygen saturation on room air. …

Staged percutaneous coronary intervention and minimally invasive valve surgery: Results of a hybrid approach to concomitant coronary and valvular disease

BACKGROUNDnWe compared a hybrid approach combining staged percutaneous coronary intervention (PCI) and minimally invasive valve surgery with concurrent valve surgery plus bypass via a median sternotomy approach.nnnMETHODSnWe retrospectively evaluated 65 consecutive patients with coronary disease and surgical valvular heart disease who underwent planned PCI followed within 60 days by minimally invasive valve surgery, and we compared them with 52 matched control patients who underwent conventional bypass grafting and valve surgery.nnnRESULTSnThere were no in-hospital deaths in the hybrid group, compared with 2 (3.8%) observed in the matched group (P = .11). Death, renal failure, or stroke occurred in 1 (1.5%) in the hybrid group versus 15 (28.8%) in the conventional group (P = .001). The median number of days between PCI and surgery was 24 (interquartile range, 2.5-37). At surgery, 23 hybrid patients were receiving both aspirin and clopidogrel;, 18, clopidogrel alone; 4, aspirin alone; and 22 stopped the antiplatelet agents 5 days before the operation. Intensive care unit hours and total hospital length of stay, including PCI stay for the hybrid group, were less in the hybrid group (P = .001 for both comparisons). In the hybrid group, average blood use was 1.6 ± 1.6 U per patient versus 1.9 ± 2.4 U per patient with conventional surgery (P = .35. There were no reoperations for postoperative bleeding in the hybrid group compared with 2 (3.8%) in the conventional group (P = .43).nnnCONCLUSIONSnStaged PCI with minimally invasive valve surgery may offer an alternative to coronary bypass grafting with concurrent valve surgery and should be tested prospectively.

Medical Therapy for Calcific Aortic Stenosis

Severe aortic stenosis due to calcification of the aortic valve is the most common indication for aortic valve replacement in the United States and Europe. The standard therapy for symptomatic patients with severe aortic stenosis is replacement of the valve. Some of the risk factors and pathophysiologic mechanisms in atherosclerosis play an important role in the development of calcific aortic stenosis. In the last few years, there have been an increased number of publications regarding the use of medications in order to delay the progression of aortic stenosis. These medications include statins, angiotensin-converting enzyme inhibitors, and biphosphanates. This article describes and summarizes some of the medical approaches that have emerged to alter the progression of aortic stenosis. Currently, only statins have been evaluated in randomized, placebo-control trials. Furthermore, statins have not proven to alter the progression of aortic stenosis. Ongoing randomized controlled trials with the use of angiotensin-converting enzyme inhibitors, statins, and biphosphonates will determine the use of these medications to delay the progression of aortic stenosis.

Review Article: Examining Treatment of ST-Elevation Myocardial Infarction: The Importance of Early Intervention

Early reperfusion in ST-segment elevation myocardial infarction (STEMI) is imperative. Acute reperfusion may be achieved with fibrinolytic agents and/or percutaneous coronary intervention (PCI); however, PCI is associated with lower rates of death and myocardial infarction compared with fibrinolysis. As treatment delays are associated with worse outcomes, current guidelines recommend minimizing time from symptom onset to treatment initiation. Regardless of the reperfusion strategy, patients with STEMI are at increased risk of early recurrent ischemic events and death. These risks can be significantly reduced by promptly initiating a combination of pharmacotherapies that includes antiplatelet and anticoagulant agents, β-blockers, and inhibitors of the renin-angiotensin-aldosterone system. This manuscript reviews the evidence supporting the most recent guidelines for STEMI management published jointly by the American College of Cardiology and American Heart Association. More recent evidence and its potential impact on future evidence-based guidelines are also addressed.

Transition from prostacyclin analogue infusion to oral therapy in patients with pulmonary arterial hypertension: a 5-year follow-up.

Transition from prostacyclin analogue infusion to oral therapy in patients with pulmonary arterial hypertension (PAH) is possible with acceptable short- and midterm results. However, there is a paucity of data on long-term outcomes after successful transition. Using a predefined protocol, transition to oral therapy was attempted in 22 patients with clinically stable PAH. Clinical and hemodynamic data were retrospectively collected at baseline as well as during and after transition. Parameters for successful versus nonsuccessful transition were also evaluated. All patients had severe PAH at baseline and showed clinical and hemodynamic improvement with prostacyclin analogue infusion. Initial oral agents used for transition were bosentan (63.6%), sildenafil (31.8%), and tadalafil (4.5%). Combination therapy was used in 68% of the patients. Successful transition was achieved in 11 patients (50%) with a mean transition duration of 16 months. After successful transition, clinical and hemodynamic parameters remained stable at midterm (mean, 18 months) and long-term (mean, 60 months) follow-up. Compared with the successful transition group, patients who experienced failure were older, had a higher frequency of idiopathic PAH, and had worse hemodynamic parameters during treatment with prostacyclin analogue alone, as well as during the transition period. In conclusion, successful transition from prostacyclin analogue infusion to oral therapy can be achieved in a significant proportion of patients with clinically stable PAH. After an initial successful transition, patients were able to maintain clinical and hemodynamic stability at the mid- and long-term follow-up.

Chronic Toxic Metal Exposure and Cardiovascular Disease: Mechanisms of Risk and Emerging Role of Chelation Therapy

Over the last few decades, there has been a growing body of epidemiologic evidence linking chronic toxic metal exposure to cardiovascular disease-related morbidity and mortality. The recent and unexpectedly positive findings from a randomized, double-blind, multicenter trial of metal chelation for the secondary prevention of atherosclerotic cardiovascular disease (Trial to Assess Chelation Therapy (TACT)) have focused the discussion on the role of chronic exposure to toxic metals in the development and propagation of cardiovascular disease and the role of toxic metal chelation therapy in the secondary prevention of cardiovascular disease. This review summarizes the most recent evidence linking chronic toxic metal exposure to cardiovascular disease and examines the findings of TACT.

La cirugía valvular mínimamente invasiva

Resumen Introduccion La cirugia valvular minimamente invasiva representa un cambio significativo en el tratamiento de las enfermedades valvulares. Este procedimiento se ha convertido en una opcion de tratamiento que puede representar menos riesgos para el paciente, especialmente si se realiza en centros que han desarrollado experiencia con la tecnica quirurgica. Metodos Revision de la literatura y reporte de experiencia con la utilizacion del metodo descrito. Resultados En cuanto a la incidencia de re-exploracion por sangramiento, fibrilacion auricular y eventos tromboembolicos no se encontro diferencia significativa entre la esternotomia media y la cirugia minimamente invasiva pero con esta ultima se observo menor necesidad de transfusiones sanguineas, menor incidencia de infecciones del esternon, al igual que menos dolor postoperatorio, corta permanencia en la unidad de cuidados intensivos y en el hospital, menos uso de analgesicos, mayor satisfaccion del paciente, reduccion en el uso de los servicios de rehabilitacion y regreso a las actividades normales. Sin embargo, existe mayor numero de accidentes cerebrovasculares asociados a la cirugia minimamente invasiva. La mortalidad entre ambas tecnicas es similar, excepto en pacientes de alto riesgo, en quienes se ha demostrado una reduccion en la mortalidad con la cirugia minimamente invasiva. Conclusiones La cirugia de minimo acceso se relaciona con recuperacion mas rapida y mayor satisfaccion para el paciente, asi como con reduccion de complicaciones postoperatorias y de la mortalidad en pacientes de riesgo alto.

High-Risk Transcatheter Aortic Valve Replacement With Evolut-R CoreValve to Simultaneously Treat Severe Calcific Aortic Stenosis and a Large Aortic Root Pseudoaneurysm

We present a case of an 81-year-old male patient with recurrent episodes of congestive heart failure. He has a medical history significant for end stage renal disease, ischemic cardiomyopathy, and severe aortic stenosis (peak/mean gradients 64/30 mmxa0Hg, aortic valve area 0.6xa0cm2) with a recent

Cardioband for the treatment of secondary mitral regurgitation: a viable percutaneous option?

Secondary mitral regurgitation (MR) remains a vexing clinical problem associated with a doubling in the risk of mortality, for patients with both ischemic and non-ischemic cardiomyopathy (1).

Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy

BACKGROUNDnWe evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery.nnnMETHODSnAll minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed.nnnRESULTSnThere were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8-20) and 42 hours (IQR, 26-93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12-61.5 hours) and 95.5 hours (IQR, 43.5-159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5-12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5-21 days) and 1 (4.3%) for AVR plus MV surgery.nnnCONCLUSIONSnIn patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality.