Luisa Salido

Asociación de la disfunción endotelial y el grosor mediointimal carotídeo con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis

Introduccion y objetivos La disfuncion endotelial y el aumento del grosor mediointimal carotideo son fenomenos tempranos en el desarrollo de la aterosclerosis, que pueden estudiarse de forma incruenta por ecocardiografia. Se pretende analizar la funcion endotelial, el grosor mediointimal carotideo y la correlacion entre ambos parametros con los factores de riesgo coronario en pacientes sin evidencia clinica de aterosclerosis. Pacientes y metodo Se incluyeron 52 sujetos, 13 sin ningun factor de riesgo coronario y 39 con al menos un factor de riesgo coronario. Se les realizo una medicion ecocardiografica de la vasodilatacion dependiente del endotelio en la arteria braquial y del grosor mediointimal en la carotida comun. Resultados En comparacion con los sujetos sin factores de riesgo coronario, los pacientes con factores de riesgo presentaron una disminucion de la vasodilatacion dependiente del endotelio: 11,98 ± 4,61% frente a 2,77 ± 2,57%, (p Conclusiones En pacientes sin evidencia clinica o complicaciones ateroscleroticas pero con factores de riesgo coronario, la funcion endotelial es peor y el grosor mediointimal carotideo es mayor que en pacientes sin ellos. Ademas, existe una asociacion lineal negativa entre la vasodilatacion dependiente del endotelio y el grosor mediointimal.

Incidence, angiographic features and outcomes of patients presenting with subtle ST-elevation myocardial infarction

BACKGROUND Borderline electrocardiograms represent a challenge in ST-segment elevation myocardial infarction (STEMI) management and are associated with inappropriate discharges and delays to intervention. OBJECTIVES To assess angiographic characteristics and outcomes of patients presenting with subtle ST-elevation (STE) myocardial infarction. METHODS A total of 504 consecutive patients with suspected STEMI treated by systematic primary percutaneous coronary intervention were prospectively included. Subtle STE was defined as a maximal preinterventional STE of 0.1 to 1 mm. Angiograms were interpreted by investigators unaware of the electrocardiographic data. RESULTS The proportion of patients with subtle STE was 18.3%, 86% of them presented with Thrombolysis In Myocardial Infarction flow grade 0/1 and 91% underwent percutaneous coronary intervention. Despite having smaller infarcts, subtle STE patients associated more frequent multivessel disease (57% vs 44%, P = .02) and larger delays to reperfusion. During a follow-up of 19.0 ± 4.9 months, the rates of death or reinfarction were similar among groups (10.0% vs 12.6%, P = .467). Subtle STE was not associated with better outcomes neither in univariate nor after adjustment in a multivariate analysis (adjusted hazard ratio 0.79, 95% CI 0.37-1.69, P = .546). CONCLUSIONS Subtle STEMI is frequent in clinical practice and is usually associated with acute total coronary occlusion. Therefore, it should be diagnosed and treated in the same expeditiously manner as marked STEMI.

Impact of thrombus burden on procedural and mid-term outcomes after primary percutaneous coronary intervention.

ObjectiveAngiographic thrombus burden (TB) can be assessed early and enable a decision on intervention. The aim of this study was to analyze its effect on the incidence of cardiac events after a primary percutaneous coronary intervention. Patients and methodsWe carried out a prospective study of 480 consecutive ST-segment elevation myocardial infarction patients treated by systematic primary percutaneous coronary intervention. Large TB was defined as thrombus length at least 2 vessel diameters or as solid thrombus obtained through catheter aspiration. The primary outcome measure was a composite of death, reinfarction, or target vessel revascularization. ResultsA total of 205 (47%) patients fulfilled the criteria for large TB. These patients were more frequently treated with abciximab (62.0 vs. 35.8%, P<0.001), showed more angiographic complications (26.6 vs. 13.7%, P=0.001), and had larger infarcts (peak troponin I, 74 vs. 50 ng/ml, P=0.015). During a follow-up of 19±5 months, the rates of primary outcome were similar between groups of small and large TB (16.2 vs. 12.8%, hazard ratio: 0.88, 95% confidence interval: 0.46–1.67, P=0.691). There were no differences in the rates of definite stent thrombosis (0.5 vs. 2.2%, P=0.190). ConclusionLarge TB is associated with larger infarct size, but not with worse mid-term outcomes. Selective use of adjuvant therapies according to TB may be an effective approach to reduce thrombotic complications.

Chronic giant hydatid cyst fistulized to the left ventricle: long-term survival without surgery

A 71-year-old woman underwent emergency evaluation due to chest pain. She had undergone lung surgery at the age of 16, due to hydatid cysts. A cyst adjacent to the pericardium was not operated due to the high risk. Chest X-ray showed a cystic image (arrow) next to the heart ( Panel A ). Two-dimensional and 3 D echocardiograms ( Panel B …

Percutaneous Intervention for Severe Aortic Stenosis and Left Main Artery Disease in a Morbidly Obese Patient

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications.

Usefulness of Reciprocal Changes in the Diagnosis of Myocardial Infarction With Minimal ST-segment Elevation.

Minimal ST-elevation often leads to inappropriate diagnoses and delayed interventions. Recent studies have shown that between 11% and 23% of infarctions do not reach the cutoff for accepted electrocardiographic criteria for infarction, and the absence of such criteria is not associated with a more favorable prognosis. The main objective of this study was to analyze the prevalence of reciprocal changes (RC) as a diagnostic tool in myocardial infarction with minimal ST-elevation. The study was based on a prospective registry of 480 consecutive patients with a definitive diagnosis of infarction who underwent emergency coronary angiography as part of a systematic primary angioplasty program between 2009 and 2011. The present study comprised 75 patients with a maximum ST-elevation of 0.01 to 0.1 mV and who could be assessed for RC. The indication for catheterization was based on persistent symptoms of ischemia. No patient received thrombolysis during the study period. Reciprocal changes were defined as J point depression 0.05 mV in the TP segment, in at least 1 lead other than the aVR lead. All patients provided informed consent prior to participation. Variables were compared using the chi-square test, the Fisher exact test, and the Mann-Whitney U test. The variables associated with RC with P < .1 (age, site, multivessel disease) were included in the multivariate logistic regression model to assess whether they were independently associated. In total, 51 patients had RC (prevalence 68%, 95% confidence interval [95%CI], 57%-79%), which was attributed to an ischemic cause in all of them. In 27 patients, a depression 0.1 mV was observed and, in all patients except 1, the slope was horizontal or decreasing. Among the 24 remaining patients, 17 showed an ST-depression of 0.01-0.04 mV (n = 15) or negative or symmetric T waves (n = 10). Overall, 68 patients had some sort of RC that supported diagnosis (91%; 95%CI, 84%-97%) (Figure). The Table shows the characteristics of the groups according to the presence of RC. In all patients, initial thrombolysis in myocardial infarction (TIMI) flow was 0/1 or creatinine kinase was elevated to more than 3 times the upper limit of normal. Although the enzyme concentrations were similar, patients with RC showed a tendency toward a higher incidence of heart failure during hospitalization (31% vs 12%; P = .080). In the analysis by infarction site, the prevalence of RC was 38% (95%CI, 8%-69%) in anterior acute myocardial infarction, 70% (95%CI 35%-100%) in lateral or inferobasal infarction, and 75% (95%CI, 63%-87%) in inferior infarction (P = .041). In the multivariate analysis, nonanterior site was independently associated with the presence of RC (odds ratio = 4.6; 95%CI, 1.3-16.1; P = .017). A I aVR

USEFULNESS OF RECIPROCAL CHANGES IN THE DIAGNOSIS OF MYOCARDIAL INFARCTION WITH MINIMAL ST-ELEVATION

Minimal ST-elevation (STE) represents a challenge in the diagnosis of myocardial infarction, and is associated with delays to intervention. We sought to analyze the prevalence of reciprocal changes as a diagnostic tool in patients with minimal STE. We conducted a prospective cohort study in a

Significant transaortic gradient after direct flow aortic valve implantation

A patient with severe aortic valve disease and high surgical risk underwent Direct Flow (DF) valve implantation. Anatomical assessment (Trans‐esophageal echocardiography (TEE) and CT scan) revealed a 3‐leaflet aortic valve (annulus diameter 23.4 mm) that was functionally bicuspid because of complete and linearly calcified fusion of noncoronary and right cusps. The valve had severe stenosis (peak/mean gradients of 70/45 mm Hg) and moderate to severe regurgitation. A balloon valvuloplasty (semicompliant 23 mm × 45 mm balloon, 2 inflations) was performed with persistence of balloon waist. A 25 DF valve was positioned in the aortic annulus, with both rings well expanded. A mild deformity in the vertical supporting tubes was observed but considered nonrelevant because valve function (peak/mean gradients of 25/12 mm Hg respectively and no aortic regurgitation) was acceptable. Then the polymer was injected and the valve released from its attachments. Postoperative course was uneventful without clinical complications; nevertheless 3 days later Doppler peak/mean transaortic gradients were 80/45 mm Hg. These high gradients were confirmed by direct invasive measurements while CT scan documented a severe geometrical deformation of the valve cuff. Since patient was in good clinical condition, a conservative strategy was adopted. Eight months later, patient functional status had improved (NYHA class II), left ventricular dimensions decreased, left ventricular ejection fraction (LVEF) increased, and valve gradients remained unchanged; therefore surgical aortic valve replacement has been deferred until clinical indication. Such a favorable course can be explained by disappearance of aortic regurgitation. Patient anatomical and procedural features that conditioned this very rare phenomenon are discussed as well as clues to prevent it.

Análisis de mortalidad en el infarto de miocardio tratado con angioplastia primaria

Fundamento y objetivo La angioplastia primaria es el metodo de reperfusion de eleccion en el infarto con elevacion del segmento ST. El objetivo de nuestro estudio ha sido determinar cuales son los factores independientes predictores de mortalidad en los pacientes con infarto de miocardio (IM) sometidos a angioplastia primaria y, por otro lado, analizar la implicacion pronostica del estudio de la perfusion tisular en estos pacientes. Pacientes y metodo Se ha realizado un estudio observacional y prospectivo de 380 pacientes tratados con angioplastia primaria, en el contexto de un IM con elevacion del segmento ST, en un unico centro. Resultados La mortalidad intrahospitalaria fue del 8,9%. En el estudio univariante, las variables asociadas a una mayor mortalidad fueron: la edad, la fraccion de eyeccion, la enfermedad multivaso, la localizacion anterior del IM, la falta de resolucion del segmento ST, el flujo TIMI 0 o 1 en la arteria causante del IM, los grados 0 o 1 del indice de blush y un tiempo de demora superior a 4 h. En el analisis multivariante las variables independientes predictoras de mortalidad fueron la edad, el grado de insuficiencia cardiaca, valorada con la escala Killip, y el grado de perfusion tisular, valorada con el indice de blush. Conclusiones Los factores independientes predictores de mortalidad en los pacientes con IM con elevacion del segmento ST tratados con angioplastia primaria son la edad, el grado de insuficiencia cardiaca segun la escala Killip y el grado de reperfusion miocardica segun el indice de blush. La resolucion del segmento ST y el indice de blush poseen un valor pronostico adicional en los pacientes con buena reperfusion epicardica.

Tratamiento percutáneo de estenosis aórtica y lesión de tronco coronario izquierdo severa en paciente con obesidad mórbida

La obesidad es un factor de riesgo para el desarrollo de complicaciones posquirurgicas e incrementa de forma significativa la tasa de mortalidad intrahospitalaria. Presentamos el caso de una mujer de 65 anos con obesidad morbida, estenosis aortica severa y enfermedad de tronco que se trato con exito mediante valvuloplastia aortica y angioplastia e implantacion de stent en tronco coronario izquierdo. Tras una intervencion quirurgica bariatrica y perder el 30% de su peso, la paciente fue aceptada en cirugia cardiaca y se le realizo recambio valvular aortico y bypass de mamaria a la descendente anterior (DA) sin complicaciones.