Luis Martínez Dolz

Puente miocárdico como causa de isquemia aguda. Descripción del caso y revisión de la bibliografía

Los puentes miocardicos estan constituidos por haces de fibras musculares que recubren un trayecto variable de una arteria coronaria epicardica, siendo un hallazgo relativamente frecuente con una incidencia que varia en funcion del metodo de estudio utilizado (angiografico/autopsia). Aunque relacionados generalmente con un pronostico benigno, cursando en muchos casos de forma asintomatica y siendo su hallazgo casual, su presencia ha sido considerada tambien como causa de angina, arritmias malignas, infarto de miocardio y muerte subita. Su diagnostico se realiza in vivo por estudio angiografico, al comprobar una compresion sistolica de una arteria coronaria que desaparece durante la diastole. Presentamos el caso de un paciente con signos electrocardiograficos de isquemia severa en el territorio de la descendente anterior que fue valorado inicialmente como infarto de miocardio y tratado como tal. En su evolucion se constato la normalizacion del ECG sin desarrollo de nuevas ondas Q de necrosis y se confirmo mediante estudio angiohemodinamico la existencia de un puente muscular aislado sobre la arteria descendente anterior en su tercio medio, sin otras lesiones coronarias asociadas.

Comparison of 1-Year Outcome in Patients With Severe Aorta Stenosis Treated Conservatively or by Aortic Valve Replacement or by Percutaneous Transcatheter Aortic Valve Implantation (Data from a Multicenter Spanish Registry)

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies.

Valor pronóstico del fibrinógeno en pacientes ingresados con sospecha de angina inestable o infarto de miocardio sin onda Q

Introduction and objective. In recent years, the relation between biological markers of inflammation and prognosis in patients suffering from acute coronary syndromes has been investigated. The aim of this study was to evaluate the association between baseline fibrinogen concentrations and the development of clinical events in patients admitted with suspicion of unstable angina and non-Q-wave myocardial infarction. Material and method. Levels of fibrinogen at enrollment were analyzed in 325 consecutive patients with acute coronary syndromes. Fibrinogen values were divided into tertiles and the incidence of clinical events was evaluated at each level. The combination of death and/or myocardial infarction was the main endpoint. Results. Fibrinogen levels were significantly higher in patients who subsequently had myocardial infarction, cardiac death, or both during follow up. The probabilities of death and/or myocardial infarction were 6%, 13%, and 29% (p < 0.0001), respectively, in patients grouped by fibrinogen tertiles (304, 305-374 and 375 mg/dl). Multivariate predictors of combined events were age, previous angina, ST-segment depression in the admission ECG, and fibrinogen into tertiles. The adjusted hazard ratio (95% CI) for patients in the upper tertile was 4.8 (1.614; p = 0.004). Conclusions. High fibrinogen levels were related to a less favorable long-term or short-term outcome in patients admitted for suspicion of unstable angina and non-Qwave myocardial infarction. This association persists after adjustment for other classical risk factors such as age, prior angina, and ST-segment depression in the ECG.Introduccion y objetivo.Durante los ultimos anos se ha investigado la relacion entre los marcadores biologicos de inflamacion y el pronostico en pacientes con sindromes coronarios agudos. Nuestro objetivo ha sido analizar la asociacion entre las concentraciones plasmaticas de fibrinogeno y la aparicion de episodios clinicos en pacientes ingresados con sospecha de angina inestable o IAM no Q. Material y metodo. Analizamos el fibrinogeno al ingre

Dosis repetidas de daclizumab para retrasar la instauración del inhibidor de la calcineurina en pacientes con trasplante cardiaco y disfunción renal postoperatoria

Daclizumab is an interleukin-2 receptor antagonist which is used for induction therapy in heart transplant patients. It has few side effects and is associated with a low infection rate. Postoperative renal failure after heart transplantation is common and potentially fatal. The administration of calcineurin inhibitors in the postoperative period can aggravate the situation. We report the cases of six patients who underwent heart transplantation and developed acute renal failure in the immediate postoperative period. All were administered daclizumab weekly to avoid the introduction of calcineurin inhibitors and to facilitate recovery of renal function. Calcineurin inhibitors were introduced only once renal function had improved. Renal function recovered in all cases and there was a low complication rate. The administration of repeated doses of daclizumab to patients who experience acute postoperative renal failure after heart transplantation may provide an alternative therapeutic approach that enables calcineurin inhibitors to be avoided and, consequently, renal function to recover.

Reversal of Protein-Losing Enteropathy After Heart Transplantation in Young Patients

Protein-losing enteropathy is a rare but life-threatening complication that occurs in some patients who develop intestinal lymphangiectasis secondary to increased systemic venous pressure. Although different forms of treatment have been tried, with varying results, the majority were reported to be unsuccessful. The aim of this study was to demonstrate that heart transplantation may be an appropriate therapeutic option for patients who do not respond to medical treatment. At our center, we performed heart transplantations in 3 patients with this condition. The mean follow-up period was 11(2) months. No patient died and the enteropathy regressed in all 3.

Técnicas de imagen en la insuficiencia cardiaca

Las tecnicas de imagen desempenan en la practica clinica un extraordinario papel, no solo en el diagnostico, sino en la valoracion pronostica y en la evaluacion del tratamiento de los pacientes con insuficiencia cardiaca. Al desarrollo en los ultimos anos de tecnicas clasicas como la ecocardiografia, la cardiologia nuclear y la tomografia computarizada se han sumado la rapida implantacion y utilizacion creciente de la resonancia magnetica en el ambito de la cardiologia. Esta amplia oferta de tecnicas de imagen hace recomendable un mayor conocimiento de su rendimiento, sus ventajas y sus inconvenientes, que nos permita realizar una seleccion mas apropiada en el estudio de este sindrome clinico. Se revisan en este articulo la utilidad y las indicaciones de las diferentes tecnicas de imagen en el manejo clinico de los pacientes con insuficiencia cardiaca.

Evolución de la insuficiencia mitral severa posvalvuloplastia

Actualmente la valvuloplastia mitral percutanea es la tecnica de eleccion para el tratamiento de la estenosis mitral reumatica con anatomia favorable. Sin embargo, la regurgitacion mitral es una complicacion importante de ese procedimiento que no ha logrado reducirse con la tecnica de Inoue. En este estudio se analiza el seguimiento clinico y ecocardiografico (28 ± 20 meses) de 20 pacientes que desarrollaron una insuficiencia mitral severa despues de la valvuloplastia mitral percutanea con el procedimiento de Inoue. Los pacientes se dividieron en dos grupos dependiendo de la necesidad de reemplazo valvular mitral durante el seguimiento. Se realizo un analisis univariado sobre parametros obtenidos antes y despues de la valvuloplastia mitral percutanea. Se practico un analisis multivariado para identificar variables predictoras independientes de la necesidad de reemplazo valvular mitral. Diez pacientes requirieron cirugia de implantacion protesica durante el seguimiento. El analisis multivariado mostro significacion estadistica en la obtencion de un area valvular tras la valvuloplastia mitral percutanea inferior a 1,5 cm2. Concluimos que un resultado suboptimo de la valvuloplastia mitral percutanea es el factor que mejor predice la necesidad de implantacion de protesis mitral a medio plazo en los pacientes que desarrollan una insuficiencia mitral severa tras la valvuloplastia mitral percutanea.

Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an Intervention

INTRODUCTION AND OBJECTIVES Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. METHODS Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. RESULTS Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). CONCLUSIONS Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.