Javier Balaguer

Endothelial dysfunction, intima-media thickness and coronary reserve in relation to risk factors and Framingham score in patients without clinical atherosclerosis.

Background Endothelial dysfunction, decreased coronary flow reserve (CFR) and increased intima–media thickness (IMT) are related to atherosclerosis and can be assessed non-invasively by echography. Objectives In order to describe the relationship between these parameters and with cardiovascular risk, this study investigated them simultaneously in patients without clinical atherosclerosis. Methods A total of 106 subjects were studied, 91 with and 15 without cardiovascular risk factors. Cardiovascular disease was excluded in all cases. Doppler ultrasound was used to analyse endothelium-dependent vascular dilation in the brachial artery, IMT in the common carotid artery and CFR in the left anterior artery. Results Patients with cardiovascular risk factors had impaired flow-mediated dilation (FMD; 3.7 ± 3.2 versus 11.6 ± 4.4%, P = 0.000); greater IMT (0.89 ± 0.3 versus 0.56 ± 0.14 mm, P = 0.000) and lower CFR (2.7 ± 0.9 versus 4 ± 1.2, P = 0.000). Correlation was found between IMT and FMD r = −0.240, (P = 0.013), IMT and CFR, r = −0.384 (P = 0.000), and between FMD and CFR of r = 0.289 (P = 0.007). All patients with IMT greater than 1 mm showed depressed FMD, most of them with low values of CFR, but patients with reduced FMD or CFR did not necessarily show increased IMT. There was a significant correlation between the three parameters and the Framingham risk score. Multiple linear regression analysis showed that IMT was the only factor related to the Framingham score. Conclusion In patients without clinical atherosclerotic disease, cardiovascular risk factors are associated with impaired FMD, CFR and increased IMT. Even though a correlation between these changes was found, they showed different dependence on cardiovascular risk factors and with global risk, IMT being the best correlated with the Framingham score.

Cierre de ductus en adultos mediante dispositivo de Rashkind: resultados comparativos

Introduccion. El cierre del conducto arterioso persistente mediante dispositivo de Rashkind es una alternativa a su correccion quirurgica en ninos y, sin embargo, existe escasa informacion sobre su utilidad en adultos. Metodo. Entre 1990 y 1996 se sometieron al cierre ductal 127 pacientes estudiando el resultado retrospectivamente. Segun la edad se clasificaron en 105 pacientes menores de 14 anos (ninos) y 22 pacientes mayores de 14 anos (adultos). El cierre se analizo mediante aortograma inmediato y ecocardiograma-Doppler color a las 24 h y a los 6 y 12 meses. Resultados. De los adultos, 19 se encontraban asintomaticos (86%) y en 13 (59%) los ductus eran silentes. Encontramos cocientes QP/QS similares (1,61 ± 0,47 en adultos frente a 1,49 ± 0,51 en ninos), pero presiones pulmonares mayores en ninos (12,50 ± 2,97 frente a 16,84 ± 5,88 mmHg; p = 0,003). En adultos, la anatomia ductal favorable (tipos A y B de Krichenko) fue mas frecuente (el 91 frente al 73%; p = 0,06) y el diametro ductal significativamente mayor (3,03 ± 1,50 frente a 2,41 ± 0,96 mm; p = 0,009). En dicho grupo se usaron mas frecuentemente dispositivos de 17 mm (el 91 frente al 61% p = 0,02). No se produjeron complicaciones (embolizacion, endarteritis, hemolisis o estenosis de ramas pulmonares) en adultos frente a un 4,72% por embolizacion en ninos. Se logro el cierre mas frecuentemente en adultos principalmente en los primeros controles: el 55 frente al 34% (p = 0,09), y el 82 frente al 69%, el 91 frente al 77% y el 95 frente al 83% (p > 0,10). El analisis multivariante identifico a la edad superior a 14 anos como predictor independiente de cierre. Conclusion. Nuestra experiencia sugiere que el cierre ductal con dispositivo de Rashkind en adultos es seguro y tanto o mas eficaz que en ninos a pesar de tratarse generalmente de ductus asintomaticos y silentes.

Análisis de las diferencias encontradas en la dilatación mediada por flujo según la terapia seguida en pacientes con enfermedad coronaria

Introduction. Flow-mediated dilation (FMD) is thought to be related to the development of coronary disease. We were interested in knowing the degree of FMD in a large sample of coronary patients in relation to the therapy they were given in clinical practice. Patients and method. We studied 1,081 coronary patients (age 68 ± 12 years, 73% male) in which FMD was evaluated in the brachial artery. The patients were classified into 5 treatment groups (416 who receive 2 or more treatments were excluded): group A: 81 controls treated with aspirin, group B: 198 treated with ACE inhibitors, group C: 106 with calcium antagonists, group D: 145 with β-blockers, and group E: 135 with lipid lowering medication (93% statins). Results. ANOVA was used to analyze the differences between groups. With regard to the number of risk factors present in each group, the patients treated with ACE inhibitors (2.44 ± 0.79 vs 2.14 ± 0.89; p 4%. Conclusion. Treatment with ACE inhibitors or statins was predictive of the normalization of FMD in coronary patients in clinical practice.

Valoración pronóstica de los pacientes con disfunción sistólica: estudio funcional y ecocardiográfico

Introduction and objectives. Multiple clinical and echocardiographic parameters have been shown to have prognostic value in cases of left ventricular dysfunction. The purpose of this paper was to evaluate the relative predictive power of such parameters. Methods. Ninety-one patients with systolic dysfunction were prospectively studied. Functional status was evaluated using the New York Heart Association classification and the 6-minute walking test. Other clinical and biochemical parameters were assessed, and an anatomic and functional echocardiographic study was performed. Results. Mean follow-up was 16.5 months (SD: 6.95). Eighteen patients died and two underwent heart transplantation (cardiac death 22%). Multiple regression analysis showed that the only independent predictor of death was functional status. Functional classes I and II showed a 16-month mortality rate of 10%, class III 40% and class IV 83%. The mortality rate was 67% for patients who walked 500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times 5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p < 0.0001. Conclusions. Functional status is the main predictor of outcome in patients with systolic dysfunction, whether assessed subjectively or estimated objectively by a walking test. Among echo-Doppler parameters, the deceleration time of the E wave and left atrial diameter gave similar prognostic information, although with less statistical significance. They can confirm or substitute the prognosis obtained by the functional classification.

Leiomiomatosis intravenosa con extensión a cavidades cardíacas

La leiomiomatosis intravenosa es una patologiatumoral uterina muy poco frecuente, caracterizadapor ser histologicamente benigna aunque puede enocasiones extenderse a traves de las venas gonadalese iliacas hasta la vena cava inferior y llegar hastalas cavidades cardiacas. Describimos un caso deuna paciente con clinica de insuficiencia cardiacaderecha y que fue diagnosticada por ecocardiografiatransesofagica de un leiomioma intravenoso conextension hasta ventriculo derecho. Se realizo excisioncompleta del tumor en un mismo acto operatorioque conllevo esternotomia y laparotomia bajocontrol ecocardiografico.

Prognostic Value of Valsalva Maneuver-Induced Change in Doppler-Detected Ventricular Filling in Patients With Systolic Dysfunction

INTRODUCTION AND OBJECTIVES In patients with systolic dysfunction, different ventricular filling patterns are associated with different prognoses. The load changes resulting from nitroprusside infusion or long-term therapy for heart failure induce alterations in filling pattern that have been shown to serve as outcome markers. Our aim was to investigate the prognostic value of the Doppler-detected change in pseudonormal or restrictive left ventricular filling pattern induced by the Valsalva maneuver in patients with systolic dysfunction. MATERIAL AND METHOD The study included 36 patients in sinus rhythm with a depressed ejection fraction and an E/A ratio greater than 1. Filling velocities were recorded before and after 3 Valsalva maneuvers. RESULTS The E/A ratio remained greater than 1 in 12 patients (group A); in 24 patients (group B), it fell below 1, indicating an abnormal relaxation pattern (i.e., a reversible pattern). During a mean follow-up period of 18 months, 8 patients died: 6 in group A (50%) and 2 in group B (8.3%; P=.005). Moreover, 12 patients either died or suffered severe heart failure: 8 in group A (67%) and 4 in group B (17%; P=.003). A reversible filling pattern was associated with lower risks of death (hazard ratio [HR]=0.06; 95% confidence interval [CI], 0.01-0.48) and of hospitalization or death (HR=0.11; 95% CI, 0.03-0.43). CONCLUSIONS Change of a pseudonormal or restrictive left ventricular filling pattern into an abnormal relaxation pattern after the Valsalva maneuver in patients with systolic dysfunction predicts a lower risk of death or severe heart failure.

Extreme Right and Left Atrial Enlargement in a Patient With Rheumatic Valvular Disease and Mitral Mechanical Prosthesis

A 75-year-old woman was admitted to the emergency room because of increasing edema. She had previously been diagnosed with rheumatic mitral disease, which required surgery with implantation of a mechanical prosthesis in 2001. At that time, pulmonary hypertension was present, and during the follow-up, she developed severe tricuspid regurgitation. A single-chamber …