Gerard Martí

Embolización percutánea de fístulas vasculares con el tapón vascular de Amplatzer o coils

Introduccion y objetivos Hay gran variedad de fistulas vasculares que son remitidas a los laboratorios de cateterismo cardiaco para su diagnostico y oclusion percutanea. Existe tambien una amplia gama de dispositivos utilizables en su tratamiento percutaneo. El objetivo es evaluar la utilidad, las dificultades, las complicaciones y los resultados en el tratamiento percutaneo de las fistulas vasculares mediante el uso de coils de liberacion controlada o tapones vasculares de Amplatzer. Metodos Revision retrospectiva de las embolizaciones percutaneas realizadas desde enero de 2004 a junio de 2008. Resultados Se embolizaron 51 fistulas vasculares en 30 pacientes con edades entre 6 dias y 28 anos (media, 8,4 anos), con buen resultado. Diagnosticos: 27 colaterales venosas en 16 pacientes con Glenn; 4 fistulas quirurgicas (Blalock-Taussig); 11 fistulas arteriovenosas pulmonares en 3 pacientes; 2 arterias colaterales aortopulmonares en 2 pacientes; 1 colateral venosa en 1 paciente con Fontan previo; 1 arteria aortopulmonar en un sindrome de cimitarra; 1 fistula arteriovenosa coronaria; 3 fistulas arteriovenosas sistemicas en 1 recien nacido, y una fistula entre auricula izquierda y vena cava superior tras la cirugia de un retorno venoso pulmonar anomalo. En el tratamiento percutaneo de estas lesiones se emplearon 34 tapones vasculares y 19 coils. Conclusiones Las fistulas vasculares pueden ser ocluidas percutaneamente con buen resultado. Los coils permiten el cierre de fistulas de menor diametro y los tapones vasculares estan indicados en las mas amplias. Ambos dispositivos alcanzan una alta eficacia oclusora y no se han observado especiales dificultades ni complicaciones significativas.

Cuantificación del área miocárdica en riesgo: validación de puntuaciones angiográficas coronarias con métodos de resonancia magnética cardiovascular

INTRODUCTION AND OBJECTIVES Quantification of myocardial area-at-risk after acute myocardial infarction has major clinical implications and can be determined by cardiovascular magnetic resonance. The Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores have been widely used for rapid myocardial area-at-risk estimation but have not been directly validated. Our objective was to compare the myocardial area-at-risk estimated by BARI and APPROACH angiographic scores with those determined by cardiovascular magnetic resonance. METHODS In a prospective study, cardiovascular magnetic resonance was performed in 70 patients with a first successfully-reperfused ST-segment elevation acute myocardial infarction in the first week after percutaneous coronary intervention. Myocardial area-at-risk was obtained both by analysis of T2-short tau inversion recovery sequences and calculation of infarct endocardial surface area with late enhancement sequences. These results were compared with those of BARI and APPROACH scores. RESULTS BARI and APPROACH showed a statistically significant correlation with T2-short tau inversion recovery for myocardial area-at-risk estimation (BARI, intraclass correlation coefficient=0.72; P<.001; APPROACH, intraclass correlation coefficient=0.69; P<.001). Better correlations were observed for anterior acute myocardial infarction than for other locations (BARI, intraclass correlation coefficient=0.73 vs 0.63; APPROACH, intraclass correlation coefficient=0.68 vs 0.50). Infarct endocardial surface area showed a good correlation with both angiographic scores (BARI, intraclass correlation coefficient=0.72; P<.001; with APPROACH, intraclass correlation coefficient=0.70; P<.001). CONCLUSIONS BARI and APPROACH angiographic scores allow reliable estimation of myocardial area-at-risk in current clinical practice, particularly in anterior infarctions. Full English text available from:www.revespcardiol.org.

MRI discriminates thrombus composition and ST resolution after percutaneous coronary intervention in patients with ST-elevation myocardial infarction.

Histological composition of material obtained by thrombus aspiration during percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute myocardial infarction (STEMI) is highly variable. We aimed to characterize this material using magnetic resonance imaging (MRI) and to correlate MRI findings with the success of PCI in terms of ST-segment resolution. Thrombus aspiration during primary or rescue PCI was attempted in 100 consecutive STEMI patients, of whom enough material for MRI was obtained in 59. MR images were obtained at 9.4T and T1 and T2 values were measured. Patients with (n = 31) and without (n = 28) adequate ST resolution 120 min after PCI (≥70% of pre-PCI value) had similar baseline characteristics except for a higher prevalence of diabetes mellitus in the latter (10 vs. 43%, p = 0.003). T1 values were similar in both groups (1248±112 vs. 1307±85 ms, respectively, p = 0.7). T2 values averaged 31.2±10.3 and 36.6±12.2 ms; in thrombus from patients with and without adequate ST resolution (p = 0.09). After adjusting for diabetes and other baseline characteristics, lower T2 values were significantly associated with inadequate ST resolution (odds ratio for 1 ms increase 1.08, CI 95% 1.01–1.16, p = 0.027). Histology classified thrombus in 3 groups: coagulated blood (n = 38), fibrin rich (n = 9) and lipid-rich (n = 3). Thrombi composed mostly of coagulated blood were characterized as being of short (n = 10), intermediate (n = 15) or long evolution (n = 13), T2 values being 34.0±13.2, 31.9±8.3 and 31.5±7.9 ms respectively (p = NS). In this subgroup, T2 was significantly higher in specimens from patients with inadequate perfusion (35.9±10.3 versus 28.6±6.7 ms, p = 0.02). This can be of clinical interest as it provides information on the probability of adequate ST resolution, a surrogate for effective myocardial reperfusion.

Percutaneous embolization of vascular fistulas using coils or Amplatzer vascular plugs.

INTRODUCTION AND OBJECTIVES A great variety of different types of vascular fistula are referred to cardiac catheterization laboratories for diagnosis and percutaneous occlusion. In addition, a wide range of devices is available for treating them percutaneously. The objectives of this study were to assess the usefulness and difficulty of treating vascular fistulas percutaneously using controlled-release coils or Amplatzer vascular plugs and to report on the complications and overall outcomes observed with these two devices. METHODS Retrospective review of percutaneous embolizations performed from January 2004 through June 2008. RESULTS In total, 51 vascular fistulas in 30 patients aged from 6 days to 28 years (mean, 8.4 years) underwent successful embolization. The underlying diagnoses were: 27 venous collaterals in 16 patients after the Glenn procedure, four surgical (i.e. Blalock-Taussig) fistulas, 11 pulmonary arteriovenous fistulas in three patients, two aortopulmonary collateral arteries in two patients, one venous collateral in a patient who underwent the Fontan procedure, one aortopulmonary artery fistula in a patient with Scimitar syndrome, one coronary arteriovenous fistula, three systemic arteriovenous fistulas in a newborn, and one fistula from the left atrium to the superior vena cava after the repair of anomalous pulmonary venous return. The lesions were treated percutaneously using 34 vascular plugs and 19 coils. CONCLUSIONS Vascular fistulas can be occluded percutaneously with good RESULTS Small fistulas can be closed using coils, while vascular plugs are preferable for large lesions. Both devices are highly effective as occluders and no particular difficulty or significant complication was observed.

CARDIAC METASTASES OF MALIGNANT MELANOMA MIMICKING SICK SINUS SYNDROME

We describe a patient with disseminated metastases from malignant melanoma manifested as symptomatic tachycardia and bradycardia that mimicked sick sinus syndrome. Autopsy showed extensive invasion of the right atrium by nodular disease.

Prognostic impact of tissue factor pathway on long-term ischemic events of ST-elevated myocardial infarction treated with a primary percutaneous coronary intervention.

pacing in Becker muscular dystrophy as assessed by tissue Doppler imaging. Heart Lung 2005;34:317–20. [10] Finsterer J, Bittner RE, Grimm M. Cardiac involvement in Beckers muscular dystrophy, necessitating heart transplantation, 6 years before apparent skeletal muscle involvement. Neuromuscul Disord 1999;9:598–600. [11] Wu RS, Gupta S, Brown RN, et al. Clinical outcomes after cardiac transplantation in muscular dystrophy patients. J Heart Lung Transplant 2010;29:432–8. [12] Finsterer J, Stollberger C, Meng G. Progressive respiratory insufficiency in the absence of cardiac disease in late-stage duchenne muscular dystrophy. Respir Care Mar 2013;58:e28–30.

Metástasis cardíacas de melanoma maligno manifestadas en forma de enfermedad del nodo sinusal

Describimos el caso de un paciente con metastasis diseminadas por melanoma maligno manifestadas en forma de taquiarritmias y bradiarritmias sintomaticas similares a las halladas en la enfermedad del nodo sinusal. El estudio necropsico mostro una extensa invasion nodular de la auricula derecha.

Left ventricular dynamic gradient and pericardial effusion. A life threatening combination in patients with apical ballooning syndrome

mortality in patients with acute myocardial infarction. Korean Circ J 2010;40: 616–24. [5] Durgan DJ, Pulinilkunnil T, Villegas-Montoya C, et al. Short communication: ischemia/ reperfusion tolerance is time-of-day-dependent: mediation by the cardiomyocyte circadian clock. Circ Res 2010;106:546–50. [6] Kim W, Park HH, Park CS, et al. Impaired endothelial function in medical personnel working sequential night shifts. Int J Cardiol 2011;151: 377–8. [7] Barion A. Circadian rhythm sleep disorders. Dis Mon 2011;57:423–37.

Short-term exposure to air pollutants increases the risk of ST elevation myocardial infarction and of infarct-related ventricular arrhythmias and mortality

BACKGROUND The relation between STEMI and air pollution (AP) is scant. We aimed to investigate the short term association between AP and the incidence of STEMI, and STEMI-related ventricular arrhythmias (VA) and mortality. METHODS The study was carried out in the area of Barcelona from January 2010 to December 2011. Daily STEMI rates and incidence of STEMI-related VA and mortality were obtained prospectively. The corresponding daily levels of the main pollutants were recorded as well as the atmospheric variables. Three cohorts were defined in order to minimize exposure bias. The magnitude of association was estimated using a time-series design and was adjusted according to atmospheric variables. RESULTS The daily rate of hospital admissions for STEMI was associated with increases in PM 2.5, PM 10, lead and NO2 concentrations. VA incidence and mortality were associated with increases in PM 2.5 and PM 10 concentrations. In the most specific cohort, BCN (Barcelona) Attended & Resident, STEMI incidence was associated with increases in PM 2.5 (1.009% per 10μg/m3) and PM 10 concentrations (1.005% per 10μg/m3). VA was associated with increases in PM 2.5 (1.021%) and PM 10 (1.015%) and mortality was associated with increases in PM 2.5 (1.083%) and PM 10 (1.045%). CONCLUSIONS Short-term exposure to high levels of PM 2.5 and PM 10 is associated with increased daily STEMI admissions and STEMI-related VA and mortality. Exposure to high levels of lead and NO2 is associated with increased daily STEMI admissions, and NO2 with higher mortality in STEMI patients.

Giant Right Atrial Myxoma and Refractory Hypoxia: An Unexpected Combination

Myxoma is the most frequent cardiac tumor, representing 50% of cases, and is considered benign, although there have been some reports of associated cerebral or pulmonary emboli. We describe the case of a woman with right atrial myxoma with an unusual clinical presentation due to the location of the tumor, which posed a difficult diagnostic dilemma. This was a 57-year-old woman who was admitted from the emergency department with a 6-month history of progressive dyspnea with associated occasional episodes of palpitations, dizziness, and general malaise. The patient had hypertension, diabetes, and obesity, but no past cardiological history. On arrival, blood pressure was 115/73 mmHg, heart rate was 78 bpm, and oxygen saturation was 80% at rest on room air, which was recorded on various occasions. Arterial blood gases showed severe hypoxemia (pO2, 49 mmHg) with hypocapnia (pCO2, 24 mmHg). There were no signs of pulmonary edema, but there were signs of right heart failure in the form of jugular venous distension, hepatojugular reflux, hepatomegaly of 2 cm, and mild ankle edema. Auscultation revealed a systolic murmur and an early diastolic tumor ‘‘plop’’ at the left parasternal edge. Electrocardiography showed sinus rhythm and an S1Q3T3 pattern. Full blood count showed mild polycythemia (hemoglobin, 16.7 g/dL; hematocrit, 51.8%). On chest X-ray, there was a mild increase in right atrial volume with no pulmonary changes. The first suspected diagnosis was pulmonary thromboembolism. However, computed tomography with contrast showed no evidence of acute emboli but did show a large mass in the right atrium (Figures A-B). Transthoracic echocardiography confirmed the existence of a mass suggestive of myxoma, which was anchored to the interatrial septum and prolapsed through the tricuspid annulus, causing obstruction during diastole, with alternating severe tricuspid regurgitationstenosis (Figure C). Pulmonary artery pressures could not be assessed. The patient was admitted to the acute coronary care unit, where, in the first few hours, persistent dyspnea and severe desaturation were recorded, which worsened on sitting up despite administration of high-flow oxygen. Cardiac telemetry revealed atrial tachycardia alternating with periods of sinus bradycardia. The patient’s refractory hypoxemia, not fully explained by the obstruction from the right atrial myxoma or by pulmonary disease, led to suspicion of an intracardiac shunt. An echocardiogram was performed with administration of agitated saline, which held the key to the diagnosis. Bubbles were observed passing into the left atrium in the first 3 cardiac cycles through a patent foramen ovale with a significant right-toleft shunt (video in supplementary material). Rev Esp Cardiol. 2016;69(12):1219–1232