Pablo Oberti

Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation

OBJECTIVES The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function. BACKGROUND Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear. METHODS We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivation cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up. RESULTS The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis. CONCLUSIONS Among patients with severe asymptomatic organic mitral regurgitation, BNP > or =105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine workup for risk stratification.

Dobutamine-Precipitated Takotsubo Cardiomyopathy Mimicking Acute Myocardial Infarction A Multimodality Image Approach

A 77-year-old woman was referred for a dobutamine stress test. She had a prior history of hypertension. Basal ECG was normal (Figure 1A). At 40 μg · kg−1 · min−1 she developed typical chest pain with ST-segment elevation in DI, DII, and the anterior leads with ventricular bigeminy (Figure 1B and 1C). The echocardiogram showed apical and mid-wall myocardial segment akinesis with basal hyperkinesis and left outflow tract gradient obstruction of 60 mm Hg. The …

Prognostic Value of Left Atrial Volume in Asymptomatic Organic Mitral Regurgitation

BACKGROUND Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. METHODS One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). RESULTS Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. CONCLUSIONS Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

Modificaciones en las perspectivas de los médicos sobre el registro médico electrónico: investigación cualitativa longitudinal

Objetivos: Conocer las creencias de los medicos sobre un registro medico electronico para la atencion ambulatoria en diferentes etapas del proceso de implementacion del sistema. Metodos: Investigacion cualitativa longitudinal basada en entrevistas en profundidad (desde julio de 2001 hasta diciembre de 2003), desarrolladas en el Hospital Italiano de Buenos Aires (Argentina). Se entrevisto a 20 cardiologos de atencion ambulatoria con perfiles profesionales diversos (muestreo intencional) antes, durante y al finalizar la implementacion del sistema (10 entrevistas por etapa). El analisis fue realizado por 2 investigadores independientes y las categorias refinadas conjuntamente. Resultados: Antes y durante la primera etapa de la implementacion los medicos esperaban que el sistema mejorara los procesos administrativos de la atencion y la disponibilidad de los datos individuales que cada uno habia registrado en consultas anteriores, pero no imaginaban que la informacion colectiva pudiera modificar los aspectos medicos de la atencion. Al finalizar la implementacion, en cambio, percibieron que el sistema les permitia acceder a una vision integral del paciente que modificaba el desempeno profesional. Durante la implementacion, los medicos opusieron el contacto con el paciente a la interaccion con el ordenador, oposicion que les impide categorizar su uso como parte del acto medico y considerar los datos del sistema como signos directos del paciente. Conclusiones: Con la implementacion, los medicos modificaron su perspectiva sobre el registro medico electronico, llegando a percibirlo como un auxiliar para la practica medica. El valor que se asigna al sistema depende de su relevancia dentro del marco institucional.

Aortic Annulus Enlargement vs. Conventional Surgery in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement

Background: The goal of aortic valve replacement for severe stenosis is to relieve symptoms and prevent the mortality associated with the disease. Appropriate prosthetic valve size must be selected for each patient according to body surface area to avoid patientprosthesis mismatch. Objective: The aim of this study was to evaluate transvalvular gradient reduction at one-year follow-up in patients with small aortic annulus undergoing valve replacement with annular enlargement vs. conventional replacement surgery. Methods: A retrospective cohort study was performed including patients with small aortic annulus undergoing valve replacement from January 2011 to December 2015. Two groups were selected: Group AAE consisting of patients in whom aortic annular enlargement was necessary and Group RVA19 involving patients in whom a #19 mm prosthetic valve was conventionally implanted. Results: Postoperative gradients (within the first 3 months and at one year) were significantly lower in the group with aortic annular enlargement. Median cardiopulmonary bypass time increased 14 minutes in Group AAE. Bioprostheses were used in most cases. There was no statistically significant difference in mortality between the groups. Conclusions: Aortic annular enlargement improves postoperative, short-term and at one year follow-up transvalvular gradients.

Síndrome de ortodeoxia-platipnea y embolia luego de endocarditis derecha complicada: consecuencias del Foramen Oval Permeable

Se presenta el caso clinico de una mujer de 63 anos de edad con Endocarditis de la Valvula Tricuspide que de-sarrollo tromboembolismo pulmonar y un sindrome de platipnea-ortodeoxia, explicado por la presencia de un formen oval permeable. La paciente se recupero satis-factoriamente despues de un reemplazo de la valvula tricuspide.