Miguel Orejas

Asociación del síndrome tako-tsubo con la arteria coronaria descendente anterior con extensa distribución por el segmento diafragmático

Introduccion y objetivos. El sindrome de disfuncion ventricular transitoria tako-tsubo ha sido descrito en Japon y se han publicado casos aislados en Occidente. Mostramos una de las primeras series descritas fuera de Japon y presentamos nueva informacion sobre su anatomia coronaria. Pacientes y metodo. Entre enero de 1998 y abril de 2003 identificamos a 11 pacientes con sospecha de infarto agudo de miocardio, arterias coronarias normales y disfuncion ventricular transitoria tipo tako-tsubo. Estudiamos la anatomia coronaria de estos 11 pacientes, asi como de 44 controles ajustados por edad y sexo: 22 con coronarias normales y 22 con infarto agudo de miocardio en relacion con oclusion en la arteria coronaria descendente anterior. Resultados. Al igual que en los pacientes japoneses, el sindrome tako-tsubo en pacientes caucasicos generalmente ocurre en mujeres en la septima u octava decadas de la vida y con frecuencia se precede de estres emocional o fisico. La arteria coronaria descendente anterior de nuestros pacientes con sindrome tako-tsubo tiene mayor longitud y un segmento diafragmatico (recurrente) mas largo que la de los controles. Para compararlos disenamos un indice de recurrencia ([segmento recurrente de descendente anterior/longitud total de la descendente anterior] x 100). En los pacientes con sindrome tako-tsubo, este indice fue del 22,3 ± 1,5%, en controles normales fue del 10,9 ± 6,7% (p < 0,001) y en los pacientes de control con infarto del 11,3 ± 7,7% (p < 0,001). Los pacientes de control con infarto presentaban una ventriculografia identica a la de los enfermos con sindrome tako-tsubo cuando su indice de recurrencia era alto (= 16%). Conclusiones. Todos nuestros pacientes con sindrome tako-tsubo presentan una descendente anterior con un gran segmento recurrente. La morfologia identica de la ventriculografia de los pacientes con sindrome tako-tsubo y los controles con infarto con un elevado indice de recurrencia de la descendente anterior puede deberse a una etiopatogenia comun.

Nuevas técnicas de imagen para la cuantificación de la carga aterosclerótica global

La aterotrombosis (aterosclerosis y sus complicaciones tromboticas) es un proceso sistemico con manifestaciones locales. Una comprension basica de los procesos implicados en la genesis y progresion de esta enfermedad permite un enfoque global orientado a un diagnostico precoz en vistas a un tratamiento temprano. El conocimiento de la carga aterosclerotica global individual es de alta importancia, ya que permite un manejo mas agresivo de los factores de riesgo. El campo de la imagen no invasiva ofrece la posibilidad de cuantificar la carga aterosclerotica en regiones accesibles (carotidas, aorta). Existen datos que sugieren una correlacion entre la carga aterosclerotica presente en dichos territorios y la existente en otros territorios menos accesibles (coronarias), y, por tanto, es posible realizar una estimacion de la carga aterosclerotica global de forma no invasiva. Nuevas modalidades como la tomografia axial computarizada con multidetectores permite explorar de forma no invasiva en el territorio coronario, con resultados altamente prometedores tanto diagnosticos como de cribado en pacientes de alto riesgo. Las tecnicas de imagen molecular permiten un abordaje no invasivo no solo de la anatomia, sino de la funcionalidad de diferentes tejidos/territorios. Estas nuevas modalidades son altamente prometedoras a la hora de realizar un diagnostico precoz de regiones de alto riesgo.

Novel Imaging Techniques for Quantifying Overall Atherosclerotic Burden

Atherothrombosis (i.e., atherosclerosis and its thrombotic complications) is a systemic disease with local manifestations. Basic understanding of the pathological processes involved in the development and progression of the disease makes it possible to adopt a general approach to early diagnosis with a view to timely treatment. Knowledge of an individuals overall atherosclerotic burden is extremely important, as it enables risk factors to be treated more aggressively. Non-invasive imaging provides a means of quantifying atherosclerotic burden in accessible areas such as the carotid arteries and the aorta. There is some evidence that there is a correlation between atherosclerotic burden in these areas and that in other less accessible areas, such as the coronary arteries. It may be possible, therefore, to obtain an estimate of overall atherosclerotic burden using non-invasive techniques. Novel imaging modalities, such as multidetector computed axial tomography, enable the coronary artery tree to be explored non-invasively, with highly promising results for both diagnosis and screening in high-risk patients. Molecular imaging techniques enable not only the anatomy but also the function of specific tissues and anatomical territories to be studied non-invasively. These new techniques provide highly promising tools for an early diagnosis in high-risk locations.

Pericardiotomía percutánea con balón en pacientes con derrame pericárdico recurrente

Background. Recurrent symptomatic pericardial effusion can complicate different cardiac and extracardiac diseases. When recurrent pericardial effusion after drainage with conventional catheter techniques occurred the creation of a pericardial window by open surgery used to be the unique treatment available until the recent development of percutaneous balloon pericardiotomy. Objective. The aim of this paper is to review our initial experience with percutaneous balloon pericardiotomy for the treatment of patients with recurrent pericardial effusion. Patientes and method. Five patients with recurrent pericardial effusion have been treated with percutaneous pericardiotomy until now. Four patients had malignant pericardial effusion secondary to metastasis of extracardiac tumors, in one patient recurrent pericardial effusion was idiopathic. In all patients percutaneous balloon pericardiotomy was performed with a pediatric valvuloplasty balloon catheter, through a subxiphoid approach. Results. Successful drainage and balloon pericardiotomy was achieved in all patients without severe complications. In all cases only one pericardial site was dilated. Minor complications were registered, which included mainly mild pleural effusion occurring in all patients with spontaneous resolution. During a mean follow-up period of 8.6 ± 6.5 months (range 2 to 18 months) there were no recurrences of effusion or tamponade. Two patients died, 1 month and 9 months after the procedure, due to their malignant condition. Conclusions. Percutaneous balloon pericardiotomy is an easy and useful technique to manage patients with large recurrent pericardial effusion with a low rate of complications.

Early Differential Resolution of Right and Left Ventricular Obliteration in Löffler Endocarditis After Chemotherapy and Anticoagulation

A 27-year-old woman diagnosed of T-cell non-Hodgkin lymphoma was referred to our hospital for allogenic hemopoietic stem cell transplantation. In childhood, the patient was diagnosed with hypereosinophilic syndrome. One week before admission, the patient started to develop progressive dyspnea. On chest x-ray, there were signs consistent with congestive heart failure. Her white cell count was 5990/mm3 with 59% eosinophils. A transthoracic echocardiogram disclosed a complete obliteration of the apexes of both ventricles, which were filled with a mildly echogenic material consistent with fibrosis or thrombosis. The right and left atria were enlarged, and pulsed wave Doppler examination showed a restrictive left ventricular (LV) filling pattern (Figure 1A through 1C). All of these findings were compatible with the diagnosis of Loffler endocarditis. The patient was anticoagulated and received conventional treatment for heart failure, resulting in clinical improvement. One week after admission, chemotherapy with fludarabine and melphalan was started, and a nonmyeloablative transplantation was carried out using hematopoietic progenitors from a human leukocyte antigen–compatible brother. Four weeks after chemotherapy, a repeat echocardiogram showed the total disappearance of the LV obliteration and a normal filling …

Parathormone levels are independently associated with the presence of left ventricular hypertrophy in patients with coronary artery disease

BackgroundAbnormalities of mineral metabolism and inflammation may affect the cardiovascular system. We have assessed the relationship of left ventricular hypertrophy (LVH) with inflammation and mineral metabolism.MethodsLVH was measured in 146 outpatients with stable coronary artery disease (SCAD) using echocardiography. Calcidiol (a vitamin D metabolite), parathyroid hormone (PTH), fibroblast growth factor-23, high-sensitivity C-reactive protein, MCP-1 (monocyte chemoattractant protein-1), galectin-3, NGAL (neutrophil gelatinase-associated lipocalin), and sTWEAK (soluble TNF-related weak inducer of apoptosis) plasma levels were studied.ResultsLVH, defined as septal thickness ≥11 mm, was present in 19.9% of cases. These patients were older [75.0 (61.0-81.0) vs 64.0 (51.0-76.0) years; p=0.002], had higher prevalence of left ventricular ejection fraction (LVEF)>40%, and had higher PTH [84.7 (59.6-104.7) vs 63.2 (49.2-85.2) pg/ml; p=0.007], galectin-3 [9.6 (8.0-11.1) vs 8.3 (6.9-9.9) ng/ml; p=0.037], and NGAL (208.5±87.6 vs 173.9±73.4 ng/ml; p=0.031) plasma levels than those without LVH. Glomerular filtration rate was lower in patients with LVH than in those without it (65.1±20.0 vs 74.7±19.9 mL/min/1.73 m2; p=0.021). There were no significant differences in hypertension (79.3 vs 68.4%; p=0.363) or sex between both groups. Variables showing differences based on univariate analysis and hypertension were entered into a logistic regression analysis. Only age [odds ratio (OR) =1.052 (1.011-1.096); p=0.013], PTH plasma levels [OR=1.017 (1.003-1.031); p=0.021], and LVEF>40% [OR=7.595 (1.463-39.429); p=0.016] were independent predictors of LVH.ConclusionsIn patients with SCAD, elevated PTH levels are independently associated with the presence of LVH. Further studies are needed to elucidate the role of PTH in the development of myocardial hypertrophy.

Tako-Tsubo Transient Left Ventricular Apical Ballooning Is Associated With a Left Anterior Descendig Coronary Artery With a Long Course Along the Apical Diaphragmatic Surface of the Left Ventricle

Introduction and objectives Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder. Patients and Methods From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery. Results As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P Conclusions All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.

Design and rationale of a multicentre, randomised, double-blind, placebo-controlled clinical trial to evaluate the effect of vitamin D on ventricular remodelling in patients with anterior myocardial infarction: the VITamin D in Acute Myocardial Infarction (VITDAMI) trial

Introduction Decreased plasma vitamin D (VD) levels are linked to cardiovascular damage. However, clinical trials have not demonstrated a benefit of VD supplements on left ventricular (LV) remodelling. Anterior ST-elevation acute myocardial infarction (STEMI) is the best human model to study the effect of treatments on LV remodelling. We present a proof-of-concept study that aims to investigate whether VD improves LV remodelling in patients with anterior STEMI. Methods and analysis The VITamin D in Acute Myocardial Infarction (VITDAMI) trial is a multicentre, randomised, double-blind, placebo-controlled trial. 144 patients with anterior STEMI will be assigned to receive calcifediol 0.266 mg capsules (Hidroferol SGC)/15 days or placebo on a 2:1 basis during 12 months. Primary objective: to evaluate the effect of calcifediol on LV remodelling defined as an increase in LV end-diastolic volume ≥10% (MRI). Secondary objectives: change in LV end-diastolic and end-systolic volumes, ejection fraction, LV mass, diastolic function, sphericity index and size of fibrotic area; endothelial function; plasma levels of aminoterminal fragment of B-type natriuretic peptide, galectin-3 and monocyte chemoattractant protein-1; levels of calcidiol (VD metabolite) and other components of mineral metabolism (fibroblast growth factor-23 (FGF-23), the soluble form of its receptor klotho, parathormone and phosphate). Differences in the effect of VD will be investigated according to the plasma levels of FGF-23 and klotho. Treatment safety and tolerability will be assessed. This is the first study to evaluate the effect of VD on cardiac remodelling in patients with STEMI. Ethics and dissemination This trial has been approved by the corresponding Institutional Review Board (IRB) and National Competent Authority (Agencia Española de Medicamentos y Productos Sanitarios (AEMPS)). It will be conducted in accordance with good clinical practice (International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use - Good Clinical Practice (ICH-GCP)) requirements, ethical principles of the Declaration of Helsinki and national laws. The results will be submitted to indexed medical journals and national and international meetings. Trial registration number NCT02548364; Pre-results.

Cardiac Arrest With ST-Segment–Elevation in V1 and V2: Differential Diagnosis

A 58-year-old male patient arrived at the emergency department following out-of-hospital cardiac arrest. He had no known cardiovascular risk factors other than smoking. His relatives reported that he had developed oppressive retrosternal chest pain and sweating 3 hours prior to presentation. The first documented rhythm was ventricular fibrillation, requiring 4 electric shocks to restore sinus rhythm and return of spontaneous circulation. The postresuscitation ECG is shown in Figure 1. What is the most likely diagnosis? Figure 1. The 12-lead ECG at the emergency room. The 12-lead ECG at the emergency room, showing ST-segment–elevation in lead V1 and V2. Please turn the page to read the diagnosis. The ECG revealed sinus rhythm, narrow QRS complex, ST-segment–elevation in lead V1 and V2, with a slight elevation in leads III and aVF and 1-mm ST-segment–depression in leads I and aVL. Surprisingly, no pathological Q waves were evidenced after more than 3 hours of chest pain. These …

Severe Right Atrial Compression by a Rapidly Growing Cardiac Mass

A 42-year-old man without a past cardiovascular history arrived in the emergency department reporting progressive chest pain, abdominal discomfort, dyspnea at rest, and orthopnea of 4 days duration. An abdominal ultrasound revealed significant pericardial and bilateral pleural effusion, with hepatomegaly and ascites of a probable congestive nature. A transthoracic echocardiogram showed severe pericardial effusion with data of hemodynamic compromise, and a right retroauricular mass anchored to the posterior atrial wall (Figures 1A and 2; Movies I and II in the online-only Data Supplement). Figure 1. A , Apical 4-chamber view transthoracic echocardiogram showing concentric severe pericardial effusion (PE), right (RV) and left (LV) ventricle, and tumor (arrow). B , CT scan showing tumor mass (arrow) attached to the right atrium (RA). C , Apical 4-chamber view with color flow Doppler demonstrating in the right chambers flow acceleration (arrow) secondary to extrinsic tumor compression. D , CT scan …