Juan Ramón Gimeno Blanes

Emergency Percutaneous Coronary Intervention in Unprotected Left Main Coronary Arteries. Predictors of Mortality and Impact of Cardiogenic Shock

INTRODUCTION AND OBJECTIVES Percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease may be essential following acute myocardial infarction (AMI). However, few data are available on the use of emergency PCI in unprotected LMCAs outside of clinical trials. The objective of this study was to determine the frequency of in-hospital mortality, its predictors and its association with cardiogenic shock, and long-term outcomes in patients with unprotected LMCA disease who undergo emergency PCI because of AMI. METHODS The study included 71 consecutive patients who underwent emergency angioplasty of the LMCA and who were followed up clinically. RESULTS Overall, 42 patients (59%) had ST-elevation AMI and 47 (66%) had cardiogenic shock or developed it during PCI. Eleven patients (16%) died in the catheterization laboratory and 33 (47%) died during hospitalization. Inhospital mortality was similar in those with and without evidence of ST-segment elevation on ECG (48% vs. 45%; P=1). Multivariate analysis showed that the predictors of in-hospital mortality were cardiogenic shock (odds ratio [OR]=4.5; 95% confidence interval [CI], 1.1-18) and incomplete revascularization (OR=5.1; 95% CI, 1.0-26). After discharge, 39 patients were followed up for a median of 32 months. Mortality in the first year was 10%. CONCLUSIONS Emergency PCI is a viable therapeutic option for AMI due to unprotected LMCA disease. However, in-hospital mortality is high, regardless of ST-segment elevation, particularly if there is cardiogenic shock or complete revascularization has not been achieved.

Rotura de balÓn y extravasaciÓn de alcohol hacia la arteria descendente anterior durante la ablaciÓn septal en paciente con miocardiopatía hipertrÓfica obstructiva

Presentamos un caso de rotura del balon de oclusion septal durante el procedimiento de ablacion con alcohol en un paciente con miocardiopatia hipertrofica obstructiva. La rotura causo reflujo de alcohol a la arteria descendente anterior y origino angina, leve hipocinesia global, transitoria de ventriculo izquierdo y bloqueo auriculoventricular avanzado. La funcion contractil se recupero en pocos minutos y el pico de creatincinasa fue de 526 U. A pesar de restaurarse el ritmo sinusal, hubo episodios de bloqueo auriculoventricular que obligaron al implante de marcapasos definitivo

Balloon Rupture and Alcohol Leakage Into the Left Anterior Descending Coronary Artery During Percutaneous Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

We present a case of rupture of the balloon during percutaneous transluminal septal myocardial ablation with alcohol in a patient with hypertrophic obstructive cardiomyopathy. Rupture of the balloon caused reflux of alcohol into the left anterior descending artery. Angina, mild global hypokinesia of the left ventricle and advanced atrioventricular block were observed. Cardiac function recovered in a few minutes and peak creatine kinase was 526 U. Despite the restoration of sinus rhythm, there were episodes of complete atrioventricular block that made permanent pacemaker implantation necessary.

Modelo de intervención coronaria percutánea primaria en la Región de Murcia

Resumen Antes de la implantacion del programa, la intervencion coronaria percutanea primaria era la excepcion en el tratamiento del infarto agudo de miocardio, a pesar de que se reperfundia con fibrinoliticos a menos del 40% de los pacientes. Desde 1998 se comenzo a tratar con intervencion coronaria percutanea primaria a todos los pacientes que acudian al Hospital Universitario Virgen de la Arrixaca. En el ano 2000, se diseno un programa de tratamiento del infarto agudo de miocardio con intervencion coronaria percutanea primaria para toda la Region de Murcia, al que se denomino APRIMUR, estableciendo una primera fase que solo incluia los tres hospitales de la capital. El programa se hizo extensible al resto de la Region en 2001. Se describe del programa sus primeras fases, el transporte, la metodologia de trabajo, los objetivos primarios y secundarios, lo que consideramos puntos clave y su sostenibilidad. Se han realizado mas de 3.500 intervenciones coronarias percutaneas primarias, con una media mensual actual de 40–45 casos. La mortalidad ha ido variando desde cifras anuales superiores al 10% a las mas actuales del 6% en 2007 y el 6,6% en 2009. Hemos conseguido que, al menos en la mitad de la Region, las cifras de reperfusion superen el 90% y vayan aumentando anualmente en el resto de las comarcas.

Value of the “Standing Test” in the Diagnosis and Evaluation of Beta-blocker Therapy Response in Long QT Syndrome

INTRODUCTION AND OBJECTIVES Patients with congenital long QT syndrome (LQTS) have an abnormal QT adaptation to sudden changes in heart rate provoked by standing. The present study sought to evaluate the standing test in a cohort of LQTS patients and to assess if this QT maladaptation phenomenon is ameliorated by beta-blocker therapy. METHODS Electrographic assessments were performed at baseline and immediately after standing in 36 LQTS patients (6 LQT1 [17%], 20 LQT2 [56%], 3 LQT7 [8%], 7 unidentified-genotype patients [19%]) and 41 controls. The corrected QT interval (QTc) was measured at baseline (QTcsupine) and immediately after standing (QTcstanding); the QTc change from baseline (ΔQTc) was calculated as QTcstanding - QTcsupine. The test was repeated in 26 patients receiving beta-blocker therapy. RESULTS Both QTcstanding and ΔQTc were significantly higher in the LQTS group than in controls (QTcstanding, 528 ± 46ms vs 420 ± 15ms, P < .0001; ΔQTc, 78 ± 40ms vs 8 ± 13ms, P < .0001). No significant differences were noted between LQT1 and LQT2 patients. Typical ST-T wave patterns appeared after standing in LQTS patients. Receiver operating characteristic curves of QTcstanding and ΔQTc showed a significant increase in diagnostic value compared with the QTcsupine (area under the curve for both, 0.99 vs 0.85; P < .001). Beta-blockers attenuated the response to standing in LQTS patients (QTcstanding, 440 ± 32ms, P < .0001; ΔQTc, 14 ± 16ms, P < .0001). CONCLUSIONS Evaluation of the QTc after the simple maneuver of standing shows a high diagnostic performance and could be important for monitoring the effects of beta-blocker therapy in LQTS patients.

Performance of a New Software Tool for Automatic Quantification of Left Ventricular Trabeculations

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