Manuel Barreiro

Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center

INTRODUCTION Primary cardiac tumors are rare entities with an autopsy frequency ranging between 0.001% and 0.3%. Our objective was to review 32 years of experience from a Spanish tertiary surgical center. METHOD We collected data on 73 patients with a histopathological diagnosis of a primary cardiac tumor in a retrospective analysis from 1979 to 2012. Tissue samples were obtained either at surgery or from necropsy and subsequently divided into benign and malignant groups. RESULTS Benign neoplasms accounted for 84.9% of cases. The average age at diagnosis was 61 years, and tumors were twice as frequent among women. It was an incidental finding in one quarter of patients. In symptomatic patients, the typical presentation was of cardioembolic stroke or of congestive symptoms. Myxoma (93.5%) was the most common diagnosis, typically affecting the left atrium (74.2%). Surgical resection was curative for 95% of these patients. Malignant tumors represented 15.1% of cases with an average age at diagnosis of 50 years. Over 90% of these patients were symptomatic at presentation with the cardinal symptom being heart failure. Undifferentiated sarcoma was the most frequent malignant tumor (36.4%). Less than 20% of patients were alive 1 year after diagnosis despite the treatment. CONCLUSIONS In our study, primary cardiac tumors were insidious. The most common was left atrial myxoma in which surgical resection was considered curative. Undifferentiated sarcoma was the most frequent malignant tumor. Malignant neoplasms carried a worse prognosis with unsuccessful total excision and the presence of metastatic disease being markers of an adverse outcome.

Management and risk factors for mortality in very elderly patients with acute myocardial infarction

Aim:  Elderly patients often remain underrepresented in clinical trials. The aim of our study was to analyze the treatment, clinical outcome and risk factors for mortality in patients aged ≥85 years with ST‐segment elevation myocardial infarction (STEMI).

Importance of Definition and Technique When Using Noninvasive Coronary Angiography to Diagnose Myocardial Bridging

First, the prevalence of MB detected by multidetector CT varies considerably. Some of this variability may be due to geographical reasons but recent technological developments in CT as well as variability in the way studies are interpreted may also play a role. Postmortem series have reported prevalence rates for MB of up to 86%, 3 which is higher than rates reported using noninvasive diagnostic techniques. This difference may be due to higher detection rates of superficial bridges during autopsy, as well as to the detection of more distant and lower calibre branches that are not detected with current CT techniques. The prevalence of MB detected using multidetector CT also appears to increase with the number of detectors. Ko et al. 4 reported a prevalence of 5,7% in patients studied with 16-row multidetector CT coronary angio

Percutaneous Venous-pulmonary Artery Extracorporeal Membrane Oxygenation in Right Heart Failure

Mechanical circulatory support with a left ventricular assist device (LVAD) is an established treatment for patients with advanced heart failure. Nonetheless, it is not free from complications, with right ventricular failure (RVF) being one of the most dreaded postprocedure events. Despite adequate risk stratification and optimal periprocedure treatment, some patients experience RVF and require a second circulatory assist device. Several devices and implantation techniques have been used for this purpose. We present the case of a patient who was treated with LVAD implantation, developed RVF, and underwent placement of a device for percutaneous venous-topulmonary artery extracorporeal membrane oxygenation (ECMO) for percutaneous right ventricular support. A 64-year-old woman with a history of dilated ischemic cardiomyopathy had severely depressed left ventricular function. In 2002, she underwent coronary artery revascularization surgery for disease of the left anterior descending artery and first diagonal artery. A left mammary to left anterior descending artery bypass and a saphenous to diagonal artery bridge were performed. The patient did not continue follow-up after the procedure. In 2015, she was admitted for heart failure. During hospitalization she showed severe left ventricular dysfunction (left ventricular ejection fraction 21%, end-diastolic volume 87 mL/m, end-systolic volume, 37 mL/m), and magnetic resonance imaging confirmed an absence of viability in the territory of the left anterior descending artery (Figure 1A). Coronary angiography showed a complex fistula that connected the left mammary arteries and left subclavian artery with the left

A Giant Left Coronary Sinus of Valsalva Aneurysm After Type A Aortic Dissection

59-year-old woman with Marfan syndrome wasreferred for cardiac computed tomography withechocardiographic diagnosis of sinus of Valsalva aneu-rysm. Twenty years earlier, she had had an aortic typeA dissection. A mechanical prosthesis and a 30-mmsupracoronary graft were implanted. The right coronaryartery was reimplanted. Cardiac computed tomographyshowed a 10 7.8 cm aneurysm arising from the left sinusof Valsalva (Fig 1; note the descending aortic dissection[arrow] and the previous reimplantation of the rightcoronary artery [arrow]). Reintervention preserved themechanical prosthesis, and the aortic root was replaced.Coronary arteries were reimplanted following Cabrol’stechnique. Most sinus of Valsalva aneurysms are congen-ital.Acquiredaneurysmsarecausedbyconditionsaffectingthe aortic wall, such as infection, degenerative disease,or thoracic trauma [1]. In our case, although Marfan syn-drome was the main condition, prior replacement of thesupracoronary aorta alone can also be followed by recur-rent aneurysm formation at the level of the residual aorticroot. As regards diagnostic tools, echocardiography andcardiac computed tomography are complementary.

Long-term survival in a patient with single ventricle.

∗ Corresponding author. E-mail address: manuelbarreiroperez@gmail.com (M. Barreiro). limiting dyspnea he underwent reoperation at the age of 29. A double-inlet ventricle, transposition of the great arteries, severe pulmonary valve stenosis and a classic Blalock-Taussig shunt with suture stenosis were described in the report of this operation. At that time a modified Blalock-Taussig shunt (Gore-Tex graft between right SA and right PA) was performed. During follow-up a cardiac pacemaker (VVI-R) was implanted. He now presented with exercise intolerance. The transthoracic echocardiogram (Figure 1) revealed a double-inlet dominant left ventricle, separated from the accessory right ventricle by a hypoplastic intraventricular septum; the atrioventricular connection was discordant. Color Doppler echocardiography showed a small right pulmonary fistula with slow bidirectional flow (Figure 2). Computed tomography angiography revealed pulmonary

Usefulness of coronary computed tomography angiography in asymptomatic patients.

We have read attentively the scientific letter by Descalzo et al., and would like to congratulate them on their interesting report. The relationship between cardiovascular risk factors and coronary artery disease has been extensively studied and, while risk scores are designed to predict cardiovascular events, they may also bear some relationship to the actual presence of the disease. To stratify our patients, the European clinical practice guidelines recommend the use of risk scores and mention the SCORE system, validated in Spain, and also recommend, although to a lesser extent, the calcium score to reclassify asymptomatic patients at moderate risk. In recent years, we have witnessed how technological advances achieved a progressive reduction in the radiation dose and an extraordinary improvement in the spatial resolution of the new coronary computed tomography scanners. The publication of multicenter studies has provided a better understanding of the diagnostic potential of this technique, and all of these factors have resulted in an exponential increase in the indications for and utilization of noninvasive coronary angiography (NCA), as is reflected in the increased number of appropriate clinical settings. However, at the present time, according to the current recommendations for appropriate use, NCA findings in asymptomatic patients would only prove to be indeterminate in those at high risk. In asymptomatic patients, like those described in the report by Descalzo et al., previous studies have documented a prevalence of coronary artery disease of 16% to 27% in the general population. However, in prospective studies, the prognostic importance of these findings is not clear. Subanalyses of the CONFIRM registry show that, in asymptomatic patients, a strategy based on NCA is not superior to the calcium score with regard to the reduction of clinical events. Thus, they do not recommend this measure because it is associated with a higher radiation dose and the need for the use of a contrast material in this subgroup of patients. Taking into account the importance and prevalence in coronary artery disease of soft plaques, which are undetectable in calcium scoring, perhaps the added value of NCA in the detection of lesions of this type should be reconsidered. In fact, studies carried out in patients at intermediate risk have revealed a higher rate of clinical events involving soft plaques, and data from the CONFIRM registry show an added potential in the stratification of the severity

Importancia de la definición y la técnica en el diagnóstico de puentes intramiocárdicos por angiografía coronaria no invasiva

Hemos leı́do con mucho interés el artı́culo publicado por de Agustı́n et al en REVISTA ESPAÑOLA DE CARDIOLOGÍA. En ese trabajo se resalta la utilidad de la angiografı́a coronaria por tomografı́a computarizada (TC) como método de detección de puentes miocárdicos (PM) en una población sintomática que por lo demás presenta baja prevalencia de enfermedad coronaria. Aunque tradicionalmente se ha reconocido a la coronariografı́a invasiva (basándose en la compresión sistólica de las arterias coronarias) como método de referencia para la valoración de PM, cada vez es más frecuente y útil su valoración anatómica no invasiva mediante angiografı́a por TC multidetectores. A juicio de los autores, puede ser de interés debatir una serie de puntos. En primer lugar, la prevalencia de PM detectada mediante angiografı́a por TC multidetectores es muy variable. Este hecho, y dejando al margen la variabilidad geográfica, puede estar relacionado con la evolución tecnológica de la TC en los últimos años, ası́ como por la variabilidad en la interpretación de los estudios. Mientras en las series necrópsicas la prevalencia de PM alcanza el 86%, su diagnóstico mediante técnicas no invasivas no ha alcanzado tasas tan elevadas. Esta disparidad puede justificarse por una mayor detección durante la autopsia de puentes superficiales, de ramas más distales y de menor calibre, que no se puede valorar con claridad mediante los tomógrafos actuales. Además, la prevalencia de PM detectados mediante angiografı́a por TC multidetectores parece aumentar según el número de detectores. Ko et al observaron una prevalencia del 5,7% en pacientes estudiados mediante TC de 16 detectores, mientras que de Agustı́n et al —y otros autores como Johanson et al o Kim et al— demostraron una prevalencia de entre el 20 y el 60% mediante TC de 64 detectores. Aún está por determinar si los más recientes aparatos de 128, 256 o 320 detectores serán capaces de diagnosticar con mayor frecuencia esta anomalı́a, ya que por su mayor resolución espacial podrı́an objetivar PM de menores longitud y profundidad. Además, las tasas de detección de PM dependen de la definición empleada. Mientras algunos estudios tienen en consideración la afección de todo el segmento visualizado (puente completo), otros autores pueden considerar que un 75% (puente parcial) de la superficie afecta es suficiente, lo que supone resultados dispares en la prevalencia de esta anomalı́a. Por otro lado, aún es objeto de debate la relación entre la clı́nica anginosa y la presencia de PM. Se ha descrito una serie de variables referentes a las caracterı́sticas anatómicas del PM (longitud, profundidad y grado de compresión sistólica) que pueden relacionarse con la aparición de sintomas. Elmali et al demostraron que, en pacientes con PM valorados por TC multidetectores, una profundidad del puente > 4 mm se relacionaba en el 100% de los casos con compresión coronaria sistólica objetivada por angiografı́a invasiva y con la aparición de clı́nica anginosa. Que de Agustin et al emplearan TC de 64 detectores, frente al de 16 detectores empleado por Elmali et al, probablemente haya permitido diagnosticar puentes de menos tamaño y profundidad, pero aun ası́ relacionados con la aparición de angina. Los hallazgos mostrados por de Agustı́n et al pueden ser importantes en un futuro cercano, ya que no se debe descartar puentes más superficiales y de menor longitud, probablemente detectados por los avances en el desarrollo de TC multidetectores, como causa de sı́ntomas de angina en pacientes sin otra causa.

Knowledge of Cardiac Disease Among Hospitalized Patients

Clinicians have a wealth of resources available to help them take existing evidence into account when making decisions. However, patients are the ones who actually have to live with the disease, so educating them should be a priority if they are to be able to adequately self-manage their condition. Clinical practice guidelines for some pathologies have made recommendations regarding patient education, but levels of patient knowledge are not all they should be. Our aim was to assess patients’ level of knowledge about their disease amongst those admitted to our unit. We interviewed 100 randomly selected patients from those admitted to the cardiology department of our tertiary hospital in March 2012. Two cardiologists independently conducted verbal interviews using a pro-forma, closed-ended survey (Table 1). The study was blinded with regard to the physicians and nurses treating the patients interviewed. On admission, patients received information about their condition and the reason for

Appropriate criteria for the use of cardiac computed tomography angiography

Dear Editor, We have read with great interest the manuscript recently published in your journal by Jin Kim et al. entitled: ‘Meaning of zero coronary calcium score in symptomatic patients referred for coronary computed tomographic angiography’.1 We completely agree with their conclusions; as it has been shown in different series previously published, that a calcium score of zero cannot rule out …