José Montiel

Infection caused by Nocardia farcinica: case report and review.

Abstract Nocardia farcinica is a rare Nocardia species causing localised and disseminated infections. A case of Nocardia farcinica infection is presented, and 52 cases previously reported in the literature are reviewed. The hosts usually had predisposing conditions (85%), and acquired the infection through the respiratory tract or skin; the infection then often spread to the brain, kidney, joints, bones and eyes. Pulmonary or pleural infections (43%), brain abscesses (30%) and wound infections (15%) which failed to respond to conventional antimicrobial therapy were the more frequent forms of infection. Nocardia farcinica was frequently isolated from pus (100% of samples), bronchial secretions (41%) and biopsy specimens (63%), but isolation from blood and urine, as in the case presented here, is rare. Antibiotic therapy was adequate in 61% of the patients in whom it was specified, the agents most frequently given being trimethoprim-sulfamethoxazole (54%), amikacin combined with imipenem (7%) and amoxicillin-clavulanate (7%). The high mortality (31%) can be attributed to the severe underlying diseases present, difficulties encountered in identifying the pathogen, inappropriate therapy and late initiation of therapy. Although an infrequent pathogen, Nocardia farcinica should be kept in mind as a cause of infection especially in immunosuppressed patients with indolent infections not responding to third-generation cephalosporins.

Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study.

BACKGROUND Minimally invasive aortic valve replacement reduces surgical trauma and, supposedly, postoperative pain, blood loss, and length of stay. A prospective, randomized study was designed to prove these theoretical advantages. METHODS Forty patients undergoing isolated, elective aortic valve replacement were randomized into two equal groups. Patients in group M underwent aortic valve replacement through a ministernotomy (reversed L or reversed C). In group S, a median sternotomy was used. The anesthetic and surgical protocol was identical for both groups. Pain was evaluated on a daily basis. Pulmonary function tests were performed preoperatively and before hospital discharge in all patients. RESULTS There were two deaths in each group. Cross-clamp time was longer in group M: 70 +/- 19 minutes versus 51 +/- 13 minutes in group S (p = 0.005). There were no statistically significant differences between groups M and S in pump time (95 +/- 20 minutes versus 83 +/- 19 minutes), extubation time (9.9 hours in both groups), chest drainage (479 +/- 274 mL/L 24 hours versus 355 +/- 159 mL/24 hours), transfusion requirements (27% in both groups), pain evaluation (1.34 +/- 1.3 versus 2.15 +/- 1.5), length of stay (6.2 +/- 2.3 days versus 6.3 +/- 2.5 days), and cosmetic appraisal. Forced vital capacity decreased 26% from preoperative reference values in group M and 33% in group S (p = not significant). Forced expiratory volume in 1 second decreased 22% and 35%, respectively (p = not significant). CONCLUSIONS This study has failed to prove the theoretical advantages of minimally invasive aortic valve replacement. With this technique, cross-clamp time is longer than with a median sternotomy.

Ruling Out Coronary Artery Disease with Noninvasive Coronary Multidetector CT Angiography before Noncoronary Cardiovascular Surgery

PURPOSE To assess the usefulness of preoperative coronary computed tomographic (CT) angiography in the detection of coronary artery disease (CAD) in nonselected patients scheduled to undergo noncoronary cardiovascular surgery to avoid unnecessary invasive coronary angiography (ICA). MATERIALS AND METHODS The institutional review board approved the study protocol; informed consent was given. This prospective study involved 161 consecutive patients who underwent coronary calcium scoring and coronary CT angiography before undergoing noncoronary cardiovascular surgery. Seven patients were excluded because of contraindications to CT angiography. The major indication of noncoronary cardiovascular surgery was valvular heart disease (121 patients). Follow-up was performed at a median of 20 months to define ischemic events described as acute coronary syndrome or death secondary to acute coronary syndrome, arrhythmias, or cardiac failure. Multivariate analysis was performed to determine predictors of nondiagnostic coronary CT angiography. Kaplan-Meier analysis was performed to evaluate outcome at follow-up. RESULTS Twenty-one patients did not undergo surgery, which left 133 patients as the study group. Atrial fibrillation was present in 45 of 133 patients. The interquartile range of the Agatston coronary calcium score was 0-471. Coronary CT angiography was diagnostic in 108 of 133 patients. Of these, 93 of 108 had no significant CAD (≤ 50% stenosis), and noncoronary cardiovascular surgery was performed in them without preoperative ICA. No patients in this group had postoperative ischemic events at follow-up. Coronary CT angiography was nondiagnostic in 25 of 133 patients who were referred for preoperative ICA. Multivariate analysis showed Agatston score to be the only independent predictor of nondiagnostic coronary CT angiography (odds ratio = 1.002; 95% confidence interval: 1.001, 1.003; P = .001). The best Agatston score cutoff for diagnostic coronary CT angiography was 579. CONCLUSION In nonselected patients scheduled to undergo noncoronary cardiovascular surgery, preoperative coronary CT angiography was diagnostic in 81% of cases. Preoperative ICA could be safely avoided in patients without significant CAD by using coronary CT angiography. The Agatston score, but not the presence of atrial fibrillation, was an independent predictor of nondiagnostic coronary CT angiography. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100384/-/DC1.

Long term outcome of mechanical valve prosthesis in the pulmonary position

OBJECTIVES Assessment of the long term outcome of mechanical valve prosthesis at pulmonary position in a population of grown-up congenital heart disease patients from a tertiary referral center. METHODS From 1977 to 2007, 22 consecutive patients underwent a total of 25 pulmonary valve replacements with mechanical prosthesis. The most frequent underlying cardiac condition was tetralogy of Fallot (n=16, 64%) and the mean age at the time of pulmonary valve replacement was 32 ± 11 years (range 14-50 years). RESULTS The postoperative mortality rate was 4% (n=1) with no late deaths documented after a mean follow-up of 7.6 ± 7.6 years (range 0.29-24 years). No major bleeding episodes occurred. Three patients presented with valve thrombosis in the setting of long term anticoagulation withdrawal and required valve re-replacement. Two of these patients, both with poor right ventricular function and overt clinical signs of right heart failure at the time of valve re-replacement, experienced further episodes of thrombosis despite correct anticoagulation. All episodes resolved with thrombolysis. After addition of antiplatelet treatment in one case and anticoagulation self-control, in the other, no further thrombosis has been documented. CONCLUSIONS Mechanical valve prosthesis may be an alternative to tissue valve prosthesis in patients with congenital heart disease requiring pulmonary valve replacement. Optimal anticoagulation is crucial and additional antiplatelet treatment should be considered. Our data also suggest that patients with severe right ventricular dysfunction and congestive heart failure might be at particular risk for valve thrombosis.

Multiple intracardiac lesions after blunt chest trauma

Closed chest trauma can cause rupture of intracardiac structures. We report the case of a 17-year-old boy whose chest was trodden by a horse. He sustained rupture of tricuspid and aortic valve leaflets and rupture of the interventricular septum. He underwent surgical repair of these lesions, but aortic insufficiency developed 2 years later and the aortic valve was replaced with a mechanical prosthesis.

Resultados de la pericardiectomía por pericarditis constrictiva crónica

The aim of this study was to assess early and late outcomes following treatment of chronic constrictive pericarditis by pericardiectomy. A retrospective analysis was carried out in 31 consecutive patients who underwent surgery between 1982 and 2005. The mean follow-up period was 6.7 years. In-hospital mortality was 16% (5/31 patients). The cause of death was low cardiac output syndrome in three patients, septic shock in one, and hemorrhage in the remaining patient. In six of the 26 surviving patients, functional class did not substantially improve and, in one patient, it worsened. The cumulative actuarial survival probability was 82% at 6 months, 82% at 1-9 years, and 64% at 10 years. In conclusion, pericardiectomy improved symptomatology in the majority of patients during late follow-up. A subgroup of patients did not experience an amelioration in clinical symptoms, probably because myocardial function did not completely recover.

Evaluación de la permeabilidad de los injertos de arteria mamaria interna izquierda mediante análisis de la velocidad del flujo por técnica Doppler transcutánea

Objetivo El objetivo del estudio fue analizar las caracteristicas de la curva de velocidad del flujo Doppler de los injertos coronarios con arteria mamaria interna en relacion con su permeabilidad determinada por angiografia selectiva. Metodos Se estudiaron 25 pacientes consecutivos portadores de un injerto de arteria mamaria interna izquierda. Se les practicaron coronariografia y estudio Doppler transcutaneo. Se cuantificaron las velocidades maximas y las integrales velocidadtiempo de los componentes sistolico y diastolico de las senales obtenidas. En la coronariografia se analizo la permeabilidad del injerto, asi como las caracteristicas angiograficas de la arteria coronaria distal a la anastomosis. Resultados Se obtuvo senal de flujo por Doppler en 23 de los 25 pacientes analizados (92%). En 17 de los 25 casos (68%) el injerto era angiograficamente permeable, siendo el flujo de predominio diastolico en 15 (88%) y sistolico en 2 (12%). En los 8 pacientes (32%) con injerto ocluido angiograficamente, 6 (75%) presentaban una senal de predominio sistolico y estaba ausente en 2 (25%). La sensibilidad y la especificidad de la presencia de un patron Doppler de predominio diastolico para la deteccion de permeabilidad del injerto fueron del 88 y del 100%, respectivamente, con un valor predictivo positivo del 100% y negativo del 80%. Conclusiones Las caracteristicas de la curva de velocidad del flujo de los injertos coronarios con arteria mamaria interna estan relacionadas con la permeabilidad del injerto, siendo la presencia de un flujo predominantemente diastolico altamente indicativa de la misma.

Orthotopic heart transplantation in a patient with situs invs, transposition of the great arteries and Mustard operation.

Orthotopic heart transplantation has become standard treatment for end-stage cardiomyopathy, but experience with this technique for complex congenital heart diseases is limited. We report a patient with visceroatrial situs invs, transposition of the great arteries and previous Mustard correction, who successfully underwent orthotopic heart transplantation.

Mixoma de ventrículo izquierdo como causa de síncope en adolescente

El diagnostico clinico de los tumores cardiacos es, a menudo, dificil. Presentamos el caso de un paciente de 17 anos en el que se diagnostico un tumor del ventriculo izquierdo a partir del estudio de un sincope. El estudio anatomopatologico confirmo el diagnostico de mixoma. Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy inwhom a left ventricular tumour was discovered duringon diagnostic work-up for a syncope. The tumourwas removed and histology confirmed thediagnosis of myxoma.

Trasplante cardiaco ortotópico en pacientes con trasposición de grandes vasos

Debido a la evolucion de la cirugia cardiaca y la cardiologia, los pacientes pediatricos que antano fallecian a causa de cardiopatias congenitas actualmente llegan a la edad adulta. Los pacientes con transposicion de grandes vasos y reparacion fisiologica en el seguimiento pueden evolucionar hacia la insuficiencia cardiaca, como consecuencia del fallo progresivo del ventriculo derecho en posicion sistemica. En esta situacion, el trasplante cardiaco aparece como una posible alternativa terapeutica. Las alteraciones anatomicas y la presencia de conductos intraauriculares hacen que el trasplante precise de una serie de variaciones tecnicas. Presentamos la experiencia en nuestro centro. Entre 1992 y 2004 se han realizado cuatro trasplantes cardiacos en transposicion de grandes vasos y correccion fisiologica. No hubo mortalidad quirurgica. Durante el seguimiento (media, 75 meses), se produjo una muerte por rechazo cronico. Los demas pacientes presentan clase I de la NYHA, con injerto normofuncionante.