Pablo Castro G

Insuficiencia cardíaca en hospitales chilenos: resultados del Registro Nacional de Insuficiencia Cardíaca, Grupo ICARO

BACKGROUND: Heart failure (HF) is a major public health problem. In Chile hospitalized patients due to HF have not been characterized. AIM: To evaluate clinical profile and outcome of patients hospitalized for heart failure in Chilean hospitals. PATIENTS AND METHODS: Prospective registry of 14 centers. Patients hospitalized for HF in functional class III and IV were included. Epidemiological and clinical data, functional class, type of presentation, decompensation cause, electrocardiogram, echocardiogram, treatment and evolution were registered. RESULTS: Three hundred seventy two patients aged 69 +/- 13 years old, 59% men, were assessed. The main etiologies of HF were ischemic in 31.6%, hypertensive in 35.2%, valvular in 14.9% and idiopathic in 7.4%. There was a history of hypertension 69%, diabetes in 35%, myocardial infarction in 22%, atrial fibrillation (AF) in 28%. The presentation form of HF was chronic decompensated in 86%, acute in 12%, refractory in 2%. The causes of decompensation were non compliance with diet or medical prescriptions in 28%, infections in 22% and AF 17%. ECG showed AF in 36% and left bundle branch block in 16%. Echocardiography was performed in 52% of the patients, 69% had left ventricular ejection fraction <40%. On admission, 39% received angiotensin converting enzyme (ACE) inhibitors, 15% beta-blocker, 25% digoxin, 16% spironolactone and 53% furosemide. The mean hospital stay was 111 +/- 10 days and mortality was 4.5%. CONCLUSIONS: The elderly is the age group most commonly admitted to hospital due to HF. The main etiologies were ischemic and hypertensive. The main causes for decompensations were noncompliance with diet or medical prescriptions and infections. A significant proportion had a relatively well preserved ventricular systolic function.

Predictores de mortalidad intrahospitalaria y hospitalización prolongada en la insuficiencia cardíaca: resultados preliminares del registro nacional de insuficiencia cardíaca. Grupo ICARO

BACKGROUND Heart failure (HF) is one of the most common causes for hospital admission. AIM To evaluate clinical predictors of mortality and prolonged hospital stay among patients admitted for HF in Chilean hospitals. PATIENTS AND METHODS Prospective registry of 14 centers. Patients admitted for HF in functional class III and IV were included. Epidemiological, clinical data, functional class, decompensation cause, electrocardiogram, echocardiogram, treatment and evolution were registered. The endpoint was hospital death and hospital stay greater than 10 days. RESULTS Data from 646 patients (mean age 69+/-13 years, 56% men) was collected. The main etiologies of HF were hypertensive in 29.6%, ischemic in 27.1% and valvular in 20%. Mean hospital stay was 10+/-9 days and mortality was 5.6%. Independent predictors of death and prolonged hospital stay were serum sodium <130 mEq/L at admission (odds ratio (OR) 2.6, confidence interval (CI) = 1.2-5.9), serum albumin <3 g/dL (OR 3.2, CI= 1.42-7.2) and a history of hypertension (OR 1.98, CI = 1.1-3.85). The model predicted correctly the occurrence of the endpoint in 67% of cases. CONCLUSIONS In patients admitted for worsening HF, low serum sodium, decreased serum albumin on admission and a history of hypertension increase the risk for in-hospital death and prolonged hospital stay.

Miocardiopatía no compactada: una serie de 15 casos

BACKGROUND: Non compaction cardiomyopathy is a rare disorder caused by the arrest of myocardial compaction during embryogenesis, leading to a non compacted endocardial layer with marked hypertrabeculation and deep recesses. AIM: To report the clinical and echocardiographic characteristics of a series of 15 adult patients with non-compaction cardiomyopathy. PATIENTS AND METHODS: We included a total of 15 patients aged 52 ± 17 years (40% males) diagnosed at our echocardiography laboratory between January 2001 and July 2010. RESULTS: The form of presentation was heart failure in 53% of subjects, syncope in 20%o, ventricular arrhythmias in 13%o and stroke in 7%>. Left ventricular end-diastolic diameter was 66 ± 11 mm and estimated ejection fraction was 27 ± 10%>. Apical and/or mid-ventricular segments of the left ventricle were involved in all the cases. Pulmonary hypertension was present in 40%o. The average follow-up was 19 months and no patient died during this period. Sixty seven percent of the patients had manifestations of heart failure, 27%o presented sustained ventricular arrhythmias and 20%> had atrial fibrillation or flutter, whereas 13%o had cerebral embolic events. An automated internal cardioverter defibrillator was implanted in 47%o of patients. CONCLUSIONS: Non-compaction cardiomyopathy is associated with high cardiovascular morbidity. The diagnosis is made in advanced stages of the disease, with significant dilation and ventricular dysfunction.

Características de la insuficiencia cardíaca en pacientes con fracción de eyección preservada: Resultados del Registro Nacional de Insuficiencia Cardíaca, Grupo ICARO

13 years, respectively. Among patients with HF and EF >50%, theproportion of women was higher (73.7 and 36.3%, p <0.001), the proportion of patients with a historyof hypertension (76.8 and 65.5%, p <0.05) and the presence of atrial fibrillation was also higher (62.3and 47.8%, p <0.01) and a history of myocardial infarction was lower (17.1 and 29.5%, p <0.05). Thediastolic diameter of the left ventricle was significantly lower in HF with preserved EF (51.0+10 and63.5+10 mm respectively, p <0.001). No differences in the length of hospital stay and mortality wereobserved between HF with depressed and preserved EF. Female gender was an independent predictorfor the presence of HF with preserved EF (Odds ratio: 2.62; confidence intervals: 1.1-6.1).

Estrés oxidativo e inflamación en insuficiencia cardiaca: Mecanismos de daño y alternativas terapéuticas

Despite advances in treatment, chronic heart failure still is associated with a poor prognosis and remains a leading cause of cardiovascular death. Cumulating evidence suggests that imbalances in redox state lead to a higher generation of reactive oxygen species. This phenomenon, along with pro-inflammatory cytokine activation and extra cellular matrix alterations with reactive fibrosis, play an important role in the pathogenesis and progression of heart failure, through the development of endothelial and myocardial dysfunction. The understanding of the underlying phenomena and the metabolic pathways involved will allow further development of therapies aiming to change the natural history of heart failure.

Tratamiento de la insuficiencia cardíaca avanzada mediante trasplante de corazón

Background: Heart transplantation currently provides the most effective treatment for advanced heart failure. However, medical therapy for this condition has also improved, heart donors are scarce and the cost of the procedure is high. Therefore the indications and management of these patients need reevaluation. Aim: To analyze the results of 24 patients submitted to heart transplantation for end-stage heart failure needing repeated hospitalizations and i.v. inotropes for compensation. Patients and methods: The group was comprised by 21 men and 3 women with a mean age of 36.8 years, mean left ventricular ejection fraction 19±4.5%, mean systolic pulmonary artery pressure 48±13 mmHg (24-70) and mean pulmonary vascular resistance 2.6 Wood Units (1-5). Fourteen patients (58%) had a previous median sternotomy. Immunosupression did not include induction therapy and steroids were discontinued early. Results: Operative mortality was 4% at 30 days. Actuarial survival at one year was 90% and at 5 years 72%. Freedom from rejection at one year was 76% and at 5 years 50%. Freedom from infection was 70% at one year and 56.5% at five years. All patients with more than 3 months of follow-up were in functional class I. Conclusions: These results justify the proposed modifications for transplantation protocols (Rev Med Chile 2001; 129: 9-17).

Miocardiopatía dilatada secundaria a enfermedad celíaca: Caso clínico

There is an increased incidence of celiac disease in patients with idiopathic dilated cardiomyopathy. We report a 4 7 year-old female presenting with heart failure secondary to dilated cardiomyopathy of unknown etiology. During the five months following the first hospitalization the patient had multiple hospital admissions due to decompensate heart failure. Due to a history of intermittent diarrhea and weight loss, a celiac disease was suspected. Antiendomysial antibodies were positive and there was a villous atrophy in duodenal mucosa. A gluten free diet was started with a concomitant recovery of her functional capacity. After one month of gluten free diet a new echocardiogram showed a normal left ventricle and systolic function.

Asistencia ventricular mecánica como puente al trasplante en pacientes en shock cardiogénico: Experiencia preliminar en Chile con ABIOMED BVS 5000 ®

Hospitalization and death due to heart failure and cardiogenic shockis frequent and currently is increasing among the adult population. Although cardiac transplantationis the most effective treatment in patients with end-stage heart failure, its availability is limited. Whilewaiting for transplantation, some patients become refractory to treatment and deteriorateprogressively. Secondary multi-organ damage could highly compromise the transplant success andalso could contraindicate it. Mechanical ventricular assist devices allow reestablishing normal cardiacoutput and they have been used as a bridge to recovery and transplantation. We report four patientsthat underwent mechanical ventricular support using the ABIOMED BVS 5000Hospitalization and death due to heart failure and cardiogenic shock is frequent and currently is increasing among the adult population. Although cardiac transplantation is the most effective treatment in patients with end-stage heart failure, its availability is limited. While waiting for transplantation, some patients become refractory to treatment and deteriorate progressively. Secondary multi-organ damage could highly compromise the transplant success and also could contraindicate it. Mechanical ventricular assist devices allow reestablishing normal cardiac output and they have been used as a bridge to recovery and transplantation. We report four patients that underwent mechanical ventricular support using the ABIOMED BVS 5000 system as a bridge for transplantation. Two patients were connected to biventricular assistance; a third patient was connected to a left ventricular support and the fourth to a right ventricular support. Three were successfully transplanted and one died of refractory non-cardiogenic shock. There were no complications related to the support system, such as infection, hemorrhage or stroke. In our experience, the ABIOMED BVS 5000 was an effective strategy as a bridge to heart transplant in patients in cardiogenic shock.

Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria: Reporte de cuatro casos

Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

Tratamiento crónico combinado con iloprost y sildenafil en un paciente con hipertensión pulmonar primaria

Iloprost, a prostacyclin analogue administered by inhalation,improves hemodynamic and functional class variables in patients with primary pulmonaryhypertension. However, repetitive inhalations are required due to its short term effects. Onepotential approach to prolong and increase the effects of aerosolized iloprost might be tocombine its use with phosphodiesterase inhibitors. We report a 36 years old female patient withprimary pulmonary hypertension treated with this combination. After 18 months of therapy thepatient had an improvement in functional class and in the 6 min walk distance despitepersistence of high pulmonary pressures. Our case is in agreement with the reported beneficialeffect of the association of sildenafil and iloprost. We postulate that functional improvement inprimary pulmonary hypertension is not always related to a decrease in pulmonary arterypressure (Rev Med Chile 2004; 132: 353-6).(