Juan Caro-Codón

Response to ECG, June 2018

The correct solution is number 3. The Figure shows a clearly prolonged QT interval in lead II, both at rest and in early and late recovery. Patients with type 1 long QT syndrome (LQTS1) have a significantly longer QTc interval in early recovery than those with type 2 long QT syndrome, and this difference disappears at about minute 4 of recovery. Thus, prolonged QTc interval at the start of recovery can specifically identify patients with LQTS1 (response 4 incorrect), whereas both genotypes have a prolonged QTc in late recovery. In the present case, the clinical diagnosis was confirmed after a mutation was found in the genetic study in exon 15 of the KCNQ1 gene (c.1760C > T p.T587 M). No electrocardiographic or echocardiographic findings supported a diagnosis of right ventricular arrhythmogenic cardiomyopathy (response 1 incorrect). The bifid and irregular T waves present in the trace, which occasionally appear in long QT syndrome, should not be confused with nonconducted P waves (response 2 incorrect).

Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management

BACKGROUND This study aimed to assess long-term cognitive and functional outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted-temperature management, investigate the existence of prognostic factors that could be assessed during initial admission and evaluate the usefulness of classic neurological scales in this clinical scenario. METHODS Patients admitted due to OHCA from August 2007 to November 2015 and surviving at least one year were included. Each patient completed a structured interview focused on the collection of clinical, social and demographic data. All available information in clinical records was reviewed and a battery of neurocognitive and psychometric tests was performed. RESULTS Seventy-nine patients were finally included in the analysis. Forty-three patients (54.4%) scored below the usual cut-off points for the diagnosis of mild cognitive impairment, even though most of these deficits went unnoticed when patients were assessed using CPC and modified Rankin scale. Nineteen (24%) developed certain degree of impairment in their attention capacity and executive functions. A significant proportion developed new memory-related disorders (43%), depressive symptoms (17.7%), aggressive/uninhibited behavior (12.7%) and emotional lability (8.9%). A greater number of weekly hours of intellectual activity and a qualified job were independent protective factors for the development of cognitive impairment. However, being older at the time of the cardiac arrest was identified as a poor prognostic factor. CONCLUSIONS There is a high prevalence of long-term cognitive deficits and functional limitations in OHCA survivors. Most commonly used clinical scales in clinical practice are crude and lack sensitivity to detect most of these deficits.

Optimal Approach for Uncrossable Stent Restenosis: Laser and Rotational Atherectomy Assessed by 3-Dimensional Optical Coherence Tomography

A 75-year-old man admitted with unstable angina underwent coronary angiography demonstrating tandem in-stent restenosis in the proximal-segment of the left anterior descending artery ([Online Video 1][1]). Optical coherence tomography (OCT) detected underoptimal stent implantation within

Dataset regarding baseline and follow-up characteristics of out-of-hospital cardiac arrest patients focused on neurological outcomes

This data article contains the data related to the research article entitled “Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management” (Caro-Codón et al., 2018). In this dataset, we report details regarding the flow chart of the included patients and the specific exclusion criteria. We also include information on the difference between the patients who attended the structured personal interview (and therefore were finally included in the study) and those who did not attend. Neuropsychiatric and functional data before and after cardiac arrest are also reported. Finally, we list all the “de novo” focal neurological deficits identified after cardiac arrest in the related population.

Extensive Chest Wall Destruction Secondary to a Large Ventricle Pseudoaneurysm: A Surgical Challenge

Left ventricular pseudoaneurysms have become a rare complication of acute myocardial infarction, occurring in approximately 2% of cases and even less frequently when primary percutaneous intervention can be performed. Regardless of treatment strategy, left ventricle pseudoaneurysms are associated with a high mortality rate. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture associated with extensive chest wall destruction and secondary traumatic rib fractures. The key to success in this case is related to both the cardiac and chest wall repair.

ST-elevation Myocardial Infarction in Anomalous Origin of Right Coronary Artery From the Left Sinus of Valsalva and Interarterial Course.

An anomalous origin of the right coronary artery (RCA) in the left sinus of Valsalva is an anatomic variant associated with ischemia, infarction, and sudden cardiac death in young patients. The prevalence of this anomaly ranges from 0.026% to 0.92% in analyzed series, typically invasive and noninvasive coronary angiography registries. This type of coronary anomaly is related to an increased presence of anatomical characteristics associated with worse prognosis, such as an interarterial or intramural course, smaller ostial diameter, and acute takeoff angle. However, there have been few cases of acute coronary syndrome related to an anomalous RCA. We present 2 such patients treated in our center (Table). The first patient was a 40-year-old man who had been resuscitated after out-of-hospital sudden cardiac arrest due to ventricular fibrillation. He received basic and advanced resuscitation for 1 hour and had inferior ST-elevation on electrocardiography. Coronary angiography failed to identify obstructive lesions in the left coronary system. The RCA was not visualized, even after multiple contrast agent injections into the right sinus, ventriculography, and aortography. The origin of the artery was finally located in the left sinus and imaging revealed complete proximal thrombotic obstruction (Figure 1A). Implantation of 2 bare-metal stents achieved a good angiographic result. After therapeutic hypothermia, the patient showed no neurological sequelae.

A giant septal diverticulum in a patient with medullary sponge kidney

Francisco Javier Irazusta*, Juan Caro-Cod on, Pablo Mer as, Mar ıa Isabel Torres, and Elena Refoyo-Salicio Department of Cardiology, University Hospital La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain; and Department of Radiology, University Hospital La Paz, Calle Costa Brava 26, 28034 Madrid, Spain * Corresponding author. Tel. 134 628938904; Fax: 134 917277050. E-mail: firazusta88@gmail.com

Three-dimensional transesophageal echocardiography in the diagnosis of biological prosthetic valve thrombosis (and its resolution).

A 73-year-old woman presented to the emergency department with a two-month history of progressive dyspnea on exertion. Fifteen months earlier she had undergone mitral valve replacement with a bioprosthesis due to severe mitral regurgitation. Her postoperative treatment included antiplatelet therapy with aspirin and oral anticoagulation, but both medications were discontinued six months after the surgery. Transthoracic echocardiography showed prolongation of mitral pressure half-time suggestive of prosthesis dysfunction (Figure 1A and B, Video 1). Transesophageal echocardiography (TEE) revealed thickening of two of the three prosthetic mitral leaflets, with restricted mobility. The anterior leaflet opened normally, resulting in severe stenosis with a total effective area of 0.81 cm calculated by three-dimensional (3D) planimetry (Figure 1C and D, Figure 2A--C, Videos 2--4). Diuretics, aspirin and anticoagulation were initiated and the patient was discharged home on day 3 with a presumptive diagnosis of prosthetic

An Unusual Case of Tricuspid Regurgitation.

We present the case of a 74-year-old woman who was referred to us with dyspnea on mild exertion. The patient had undergone surgical commissurotomy to treat rheumatic mitral stenosis at the age of 28 years, and 29 years later, underwent a second intervention for mitral and tricuspid valve replacement with a double mechanical prosthesis. Ten years before coming to us, she had had surgery at another center for pacemaker implantation due to atrioventricular block; since then, she had not undergone follow-up. In addition to marked cardiomegaly attributable to enlargement of the right chambers, the radiographic study (Figure 1A and 1B) showed the end of the pacemaker lead passing through the tricuspid valve prosthesis and into right ventricle. A transthoracic echocardiogram confirmed the passage of the lead through the prosthesis, which was somewhat thickened and showed evidence of fibrosis, and was associated with severe regurgitation (Figure 2A and 2B, videos 1-3 of the supplementary material). Subsequent transesophageal echocardiography showed a normally functioning mitral valve prosthesis and confirmed the findings of the transthoracic study (Figure 2C, transmitral gradients; Figure 2D, reconstruction of the tricuspid valve prosthesis; videos 4-6 of the supplementary material). The images obtained by fluoroscopy (Figure 3A and 3B, videos 7 and 8 of the supplementary material) demonstrated the interaction between prosthesis and lead, which impeded the closure of the medial hemidisc of the former during systole. After 3 years of follow-up, the patient remains in New York Heart Association class II and refuses to undergo an intervention to remove the lead. This case, the first in the literature, shows that the passage of a permanent pacemaker lead through a bileaflet mechanical prosthesis is unacceptable, as it triggers severe valve regurgitation and increases the risk of degeneration of the lead and of the prosthesis itself over time.

A Marble in the Heart

An 83-year-old woman with chronic atrial fibrillation and hypertension underwent left atrial appendage occlusion at another center with a 22-mm Amplatzer cardiac plug (St. Jude Medical, Minneapolis, Minnesota) after embolic central retinal artery occlusion while receiving treatment with dabigatran.