Jorge Martinez

Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple-Vessel Disease (ERACI II): 30-Day and One-Year Follow-up Results

OBJECTIVEnThe purpose of this study was to compare percutaneous transluminal coronary revascularization (PTCR) employing stent implantation to conventional coronary artery bypass graft surgery (CABG) in symptomatic patients with multivessel coronary artery disease.nnnBACKGROUNDnPrevious randomized studies comparing balloon angioplasty versus CABG have demonstrated equivalent safety results. However, CABG was associated with significantly fewer repeat revascularization procedures.nnnMETHODSnA total of 2,759 patients with coronary artery disease were screened at seven clinical sites, and 450 patients were randomly assigned to undergo either PTCR (225 patients) or CABG (225 patients). Only patients with multivessel disease and indication for revascularization were enrolled.nnnRESULTSnBoth groups had similar clinical demographics: unstable angina in 92%; 38% were older than 65 years, and 23% had a history of peripheral vascular disease. During the first 30 days, PTCR patients had lower major adverse events (death, myocardial infarction, repeat revascularization procedures and stroke) compared with CABG patients (3.6% vs. 12.3%, p = 0.002). Death occurred in 0.9% of PTCR patients versus 5.7% in CABG patients, p < 0.013, and Q myocardial infarction (MI) occurred in 0.9% PTCR versus 5.7% of CABG patients, p < 0.013. At follow-up (mean 18.5 +/- 6.4 months), survival was 96.9% in PTCR versus 92.5% in CABG, p < 0.017. Freedom from MI was also better in PTCR compared to CABG patients (97.7% vs. 93.4%, p < 0.017). Requirements for new revascularization procedures were higher in PTCR than in CABG patients (16.8% vs. 4.8%, p < 0.002).nnnCONCLUSIONSnIn this selected high-risk group of patients with multivessel disease, PTCR with stent implantation showed better survival and freedom from MI than did conventional surgery. Repeat revascularization procedures were higher in the PTCR group.

Complications of emergency intubation with and without paralysis

Expert and definitive airway management is fundamental to the practice of emergency medicine. In critically ill patients, rapid sedation and paralysis, also known as rapid-sequence intubation, is used to facilitate endotracheal intubation in order to minimize aspiration, airway trauma, and other complications of airway management. An alternative method of emergent endotracheal intubation, intubation minus paralysis, is performed without the use of neuromuscular blocking agents. The present study compared complications of these two techniques in the emergency setting. Sixty-seven intubations minus paralysis were prospectively compared with 166 rapid-sequence intubations. Complications were greater in number and severity in the nonparalyzed group and included aspiration (15%), airway trauma (28%), and death (3%). None of these difficulties were observed in the rapid-sequence group (P < .0001). These results show that rapid-sequence intubation when compared with intubation minus paralysis significantly reduces complications of emergency airway management and should be made available to emergency physicians trained in its use.

In-Hospital and Late Results of Coronary Stents Versus Conventional Balloon Angioplasty in Acute Myocardial Infarction (GRAMI trial)☆

One hundred four patients presenting with acute myocardial infarction < 24 hours after onset were randomized to 2 groups: group I (n = 52) was treated with balloon angioplasty followed electively with Gianturco Roubin II stents, and group II was treated with conventional balloon angioplasty alone (n = 52). All lesions were suitable for stenting. Baseline clinical, demographic, and angiographic characteristics were similar in the 2 groups. Procedural success was defined as no laboratory death or emergent coronary bypass, Thrombolysis In Myocardial Infarction (TIMI) trial 2 or 3 flow after the procedure in a culprit vessel, and a residual stenosis < or = 30% for coronary angioplasty and < 20% for stent. Procedural success was 98% in group I versus 94.2% in group II, p = NS. Thirteen patients in group II (25%) had bailout stenting during the initial procedure. Adverse in-hospital events including either death, nonelective coronary bypass, recurrent ischemia, and reinfarction occurred in 3.8% in group I versus 19.2% in group II, p = 0.03. Repeat angiography performed routinely before hospital discharge revealed TIMI 3 flow in the infarct-related artery in 98% in group I versus 83% in group II, p < 0.03. At late follow-up, event-free survival was significantly better in the stent (83%) than in the coronary angioplasty (65%) group (p = 0.002). The procedural in-hospital and late outcomes of this randomized study demonstrate that balloon angioplasty followed electively by coronary stents can be used as the primary modality for patients undergoing coronary interventions for acute myocardial infarction, increasing TIMI 3 flow, reducing in-hospital adverse events, and improving late outcome compared with balloon angioplasty alone.

Evaluation of Fontan's operation by magnetic resonance imaging

Abstract Fontan-type procedures for tricuspid atresia 1–3 and the modifications used for other complex cyanotic cardiac malformations 4,5 should be judged by the complications and long-term state of patients. 6 The most important complication is insidious obstruction. Early recognition of this is vital since it can lead to arrhythmias and loss of atrial and ventricular function. At catheterization attention must be paid to small gradients as low as 2 or 3 mm Hg. A reliable noninvasive method for assessing the atriopulmonary connection as well as the cardiac function applicable to outpatients is necessary for proper management. Magnetic resonance imaging (MRI) has been used as a noninvasive method of assessing congenital heart disease, both pre- and postoperatively. 7–10 This study assesses its value for demonstrating the anatomy of the atriopulmonary connection and recognizing obstruction compared to 2-dimensional echocardiography and the findings at catheterization and operation.

Changes by two-dimensional echocardiography in the myocardial appearance of patients with end-stage renal disease

A retrospective study of the clinical and biochemical data of all patients with end-stage renal disease who underwent 2-dimensional echocardiography at Tulane Medical Center between 1982 and 1986 was performed. Complete echocardiographic data were available for comparison in 53 patients. Highly reflective echoes were judged to be present in the myocardium of 81% of the patients. This characteristic is described as a glistening speckled appearance. Patients with this characteristic had significantly greater left ventricular mass index (p = 0.0021).

Cardiac Contusion with Early Ventricular Rupture—A Case Report:

Myocardial contusion is a common concomitant of high-speed deceleration injuries in our modern society. Despite increasing awareness of this entity among health care professionals, in many cases the diagnosis remains a difficult one to make because of a scarcity of physical signs. The diagnosis is, however, extremely important because of the possible complications, which include low cardiac output state, conduction defects, atrial and ventricular dysrhythmias, and, rarely, even cardiac rupture. Much less common, but also clinically impor tant, is rupture of the free cardiac wall from blunt trauma. A case of cardiac contusion caused by blunt trauma sustained in a motor vehicle accident complicated by early ventricular rupture is presented. Ten hours after arrival at the hospital, this patient abruptly became hypotensive and sustained a cardiopulmonary arrest, which did not respond to the usual medical measures. Upon open thoracotomy the patient was found to have suffered a right ventricular rupture, which was repaired; however, the patient subse quently expired.