Juan Medina

Valor de la troponina I cardíaca como prueba diagnóstica en el estudio del dolor torácico

Introduccion y objetivos La troponina I cardiacaes un marcador muy sensible y especifico de lesionmiocardica. Hemos analizado si la determinacionde cifras de troponina I cardiaca puede ser util enel diagnostico de cardiopatia isquemica, en pacientespreviamente sanos con clinica de dolor toracicosin que el resto de analitica ni el ECG sean suficientementediagnosticos. Pacientes, material y metodos Se estudiarontransversal y consecutivamente durante un ano untotal de 37 pacientes sin cardiopatia previa conocida,ingresados en la unidad coronaria por dolor toracicosupuestamente anginoso, con enzimas cardiacasy ECG normales. Se consideraron como patologicascifras de troponina I cardiaca al ingreso ≥ 0,4 ng/ml, contrastandose con los resultados de lacoronariografia o de una ergometria concluyente yrelacionandose tambien con la duracion del cuadroy el tiempo de demora entre los sintomas y la extraccionde la muestra. Resultados Fueron estudiados 33 de los 37 pacientesinicialmente incluidos. En 22 se diagnosticocardiopatia isquemica elevandose la troponina I en15 de ellos; se obtuvo una sensibilidad del 68% (48-84%), con una especificidad del 82% (53-97%). Enel subgrupo de pacientes con dolor ≥ 30 min de duracionla sensibilidad ascendio al 85% (59-97%),con una especificidad del 83% (42-99%). No huboresultados significativamente diferentes en funciondel tiempo de demora. Conclusiones La troponina I cardiaca resultamuy util en el estudio de dolores toracicos supuestamenteanginosos sin enzimas ni ECG concluyentes,ya que posee una elevada sensibilidad y especificidadpara la deteccion de lesion isquemica. Estacapacidad diagnostica se acentua en el caso de doloresprolongados.

Homoinjerto de raíz aórtica para el tratamiento quirúrgico de las afecciones de la válvula aórtica con aorta ascendente dilatada

Introduccion y objetivos. Los pacientes con afeccion de la valvula aortica y dilatacion de la aorta ascendente son tratados habitualmente con tubos valvulados. Revisamos los resultados del uso de homoinjertos de raiz aortica como alternativa terapeutica valida. Pacientes y metodo. Se incluyo en el estudio a un total de 22 pacientes consecutivos con una edad media, 64,8 ± 8,8 anos. La dilatacion media de la aorta ascendente fue de 54,45 mm y la valvula aortica presentaba insuficiencia pura en 16 pacientes; en 6 pacientes habia doble lesion. En todos los casos se usaron homoinjertos criopreservados para sustituir la raiz aortica y la aorta ascendente. En 9 casos se prolongo la union sinotubular con una protesis para restablecer la continuidad entre el homoinjerto y la aorta nativa. Resultados. No hubo muertes hospitalarias ni en el seguimiento. Un paciente padecio un sindrome de respuesta inflamatoria sistemica y otro fue reintervenido por hemorragia. El seguimiento medio fue de 12,1 meses (rango, 2-36 meses). No se administro anticoagulacion a ningun paciente. Un paciente tuvo un accidente cerebrovascular transitorio sin secuelas. Se observo mediante ecocardiografia una reduccion estadisticamente significativa de los diametros ventriculares al mes de la cirugia (diametro sistolico del ventriculo izquierdo p < 0,001; diastolico, p < 0,009) que se mantuvo durante el seguimiento. Todos los enfermos presentan calibre normal de la aorta ascendente (= 30 mm), excepto uno. Conclusiones. Los homoinjertos de raiz aortica constituyen una alternativa valida para el tratamiento de las afecciones de la valvula aortica asociadas a dilatacion de la aorta ascendente. La no necesidad de anticoagulacion y la rapida recuperacion de los diametros ventriculares izquierdos son los pilares fundamentales de este tratamiento.

Outcomes of patients at estimated low surgical risk undergoing transcatheter aortic valve implantation with balloon-expandable prostheses

INTRODUCTION AND OBJECTIVES Transcatheter aortic-valve implantation (TAVI) is an accepted treatment for patients with severe aortic stenosis and high surgical risk. However, there is lack in data about TAVI in low-risk patients that are already being treated with this therapy in some clinical contexts. METHODS A retrospective analysis of patients treated with transfemoral TAVI using Edwards Sapien prosthesis in one center was performed, classifying the patients into three groups according to the surgical risk (high/intermediate/low risk for STS score>8/4-8/<4). Clinical characteristics, procedure and follow-up outcomes were collected, comparing the results between low and high surgical risk groups. RESULTS 89 TAVIs using Edwards balloon expandable prosthesis were performed (9 Sapien XT and 80 Sapien 3 valves were implanted). 40 patients (45%) presented a STS score<4, while 33 (37%) had a STS>8. Low-risk patients were significantly younger and had lower rates of coronary artery disease, peripheral vascular disease, pulmonary lung disease and atrial fibrillation. There were no significant differences in most of the technical variables of the procedure, apart from vascular complications and complete left bundle branch block after valve implant, which were higher in the group with STS>8. Patients of low risk presented shorter hospital stay (2,91±1,6, vs 4,8±3,9 days), with lower rates of mortality at mid- and long follow-up (death from any cause 15,2% vs 0%, p 0,04). CONCLUSIONS TAVI in low-risk patients is safe and associated with better outcome at mid and long-term follow-up compared to high-risk patients.

In-frame Variants in FLNA Proximal Rod 1 Domain Associate With a Predominant Cardiac Valvular Phenotype

INTRODUCTION AND OBJECTIVES X-linked cardiac valvular dysplasia is a rare form of male-specific congenital heart defect mainly characterized by myxomatous degeneration of the atrioventricular valves with variable hemodynamic consequences. It is caused by genetic defects in FLNA-encoded filamin A, a widely expressed actin-binding protein that regulates cytoskeleton organization. Filamin A loss of function has also been associated with often concurring neurologic and connective tissue manifestations, with mutations in the first half of the Rod 1 domain apparently expressing the full cardiac phenotype. We contribute to previous genotype-phenotype correlations with a multidisciplinary approach in a newly-described family. METHODS Cardiologic, dysmorphologic, and genetic evaluation of available members were complemented with transcriptional and X-chromosome inactivation studies. RESULTS A novel FLNA mutation c.1066-3C>G cosegregated with a male-expressed, apparently isolated, cardiac phenotype with no skewed X-inactivation pattern in female carriers. This variant was shown to result in an in-frame deletion of 8 amino acid residues near the N-terminal region of the protein. CONCLUSIONS A nonimprinted, partial loss of function of filamin A proximal Rod 1 domain seems to be the pathogenetic mechanism of cardiac valvular dysplasia, with some cases occasionally expressing associated extracardiac manifestations.

Aortic Root Homograft in the Surgical Treatment of Aortic Valve Disease With Dilated Ascending Aorta

INTRODUCTION AND OBJECTIVES Patients with aortic valve disease and a dilated ascending aorta are usually treated with a composite graft comprising a valve and conduit. We review here the results of treatment with an aortic root homograft as a valid alternative. PATIENTS AND METHOD Twenty-two consecutive patients with a mean age of 64.8 (8.8) years were studied. Mean ascending aorta dilation was 54.55 mm, aortic valve insufficiency was present in 16 patients, and a combined lesion was present in 6. In all cases a cryopreserved aortic root homograft was used to replace the aortic valve and ascending aorta. In 9 cases a Dacron conduit was used beyond the sinotubular junction to restore continuity between the homograft and the native aorta. RESULTS All patients survived surgery. One patient had postoperative systemic inflammatory response syndrome and one patient was re-explored for excessive bleeding. Mean duration of follow-up was 12.1 months (range 2-36 months). No patient was given anticoagulants, and one had an early transient cerebrovascular accident followed by complete recovery. At one month postsurgery the left ventricular systolic (P<.001) and diastolic (P<.009) diameters had decreased significantly on echocardiography, and these decreases persisted throughout follow-up. The caliber of the ascending aorta was normal in all patients (< or =30 mm) except one. CONCLUSIONS Aortic root homografts are a valid alternative in the treatment of aortic valve disease with ascending aorta dilation. The main advantages of this therapy are that permanent anticoagulation is not needed, and that left ventricular dimensions recover rapidly.

Myocardial Infarction and 5,10-Methylenetetrahydro-folate Reductase Gene Mutation

A 40-year-old woman with previous venous thrombosis in the lower limbs had recurrent myocardial infarction in the early puerperium. The only documented risk factor was an elevated level of plasma homocysteine, associated to a heterozygotic anomaly in the enzyme responsible for its metabolism, 5,10-methylenetetrahydrofolate reductase. The case and approaches to treatment are discussed.