Francisco José González Domínguez

Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: Sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria☆

When ventricular free wall rupture after acute myocardial infarction is not followed by sudden death, it is referred to as subacute ventricular rupture. The sensitivity and specificity of clinical, hemodynamic and echocardiographic diagnostic variables obtained at bedside are unknown and were therefore prospectively studied in 1,247 consecutive patients with acute myocardial infarction including 33 patients with subacute ventricular rupture diagnosed at operation (group A) and 1,214 patients without ventricular rupture (at operation, postmortem study or at discharge) (group B). The incidence of syncope, recurrent chest pain, hypotension, electromechanical dissociation, cardiac tamponade, pericardial effusion, high acoustic intrapericardial echoes, right atrial and right ventricular wall compression identified in two-dimensional echocardiograms and hemopericardium demonstrated during pericardiocentesis was higher in group A than in group B (p less than 0.00001). The presence of cardiac tamponade, pericardial effusion greater than 5 mm, high density intrapericardial echoes or right atrial or right ventricular wall compression had a high diagnostic sensitivity (greater than or equal to 70%) and specificity (greater than 90%). The number of false positive diagnoses was always high for each diagnostic variable alone (greater than 20%), but the combination of clinical (hypotension), hemodynamic (cardiac tamponade) and echocardiographic variables allowed a sensitivity of greater than or equal to 65% with a small number of false positive diagnoses (less than 10%) and provided useful information for therapeutic decisions. The diagnosis of subacute ventricular rupture requires a surgical decision. Twenty-five (76%) of the 33 patients with subacute ventricular rupture survived the surgical procedure and 16 (48.5%) are long-term survivors. Thus, subacute ventricular wall rupture is a relatively frequent complication after acute myocardial infarction that can be accurately diagnosed and successfully treated.

Balloon percutaneous valvuloplasty for stenotic bioprosthetic valves in the mitral position

Abstract Percutaneous balloon valvuloplasty is useful for treatment in some patients with valvular stenosis, including those with severe calcification of the valve. 1–4 One case of dilatation of a tricuspid bioprosthetic valve was reported, 4 but none at other positions has been reported. We report the performance and the angiohemodynamic effects of in vivo dilatation in 2 patients with stenotic bioprosthetic valves in the mitral position.

Effectiveness of balloon percutaneous valvuloplasty for stenotic bioprosthetic valves in different positions

Abstract Percutaneous balloon valvuloplasty has been used as treatment for native valvular stenosis in the mitral, aortic, pulmonary and tricuspid positions. 1–4 It has also been used as palliative therapy for stenotic bioprosthetic valves. 5–8 In this study we present the immediate results and midterm follow up of percutaneous balloon valvuloplasty of 5 bioprosthetic valves in different positions.

Endocarditis protésica y absceso esplénico causados por Clostridium clostridiformis

Presentamos el primer caso documentado de endocarditispor Clostridium clostridiformis, en unenfermo de 71 anos de edad con una protesis biologicaaortica. El enfermo presento sindrome febrilacompanado de dolor en flanco y hemitorax izquierdocon una imagen radiologica de infiltradoen el lobulo inferior izquierdo. El diagnostico fuerealizado mediante el crecimiento del germen entres hemocultivos. Se realizo un estudio ecocardiograficotranstoracico y transesofagico mostrandoun absceso paraaortico. La TAC abdominal demostrola existencia de un gran absceso esplenico. Elpaciente fue tratado mediante penicilina G sodica adosis de 4 millones de unidades cada 4 horas. Sepractico con exito drenaje percutaneo del abscesoguiado por TAC, tras lo cual el paciente permaneciofebril y en una nueva TAC abdominal de controlse observo la existencia de absceso residual, traslo cual se practico esplenectomia quirurgica. Desdeel segundo dia de la cirugia el paciente permanecioafebril durante toda su hospitalizacion y dos anosmas tarde permanece asintomatico.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

Background: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. Methods: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22–92), 443 type A (70.4%) and 186 type B (29.6%). Results: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th–75th percentiles, 2.7–15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1–3, 2.5–11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. Conclusion: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.