Pablo Robles

Endocarditis protésica y absceso esplénico causados por Clostridium clostridiformis

Presentamos el primer caso documentado de endocarditispor Clostridium clostridiformis, en unenfermo de 71 anos de edad con una protesis biologicaaortica. El enfermo presento sindrome febrilacompanado de dolor en flanco y hemitorax izquierdocon una imagen radiologica de infiltradoen el lobulo inferior izquierdo. El diagnostico fuerealizado mediante el crecimiento del germen entres hemocultivos. Se realizo un estudio ecocardiograficotranstoracico y transesofagico mostrandoun absceso paraaortico. La TAC abdominal demostrola existencia de un gran absceso esplenico. Elpaciente fue tratado mediante penicilina G sodica adosis de 4 millones de unidades cada 4 horas. Sepractico con exito drenaje percutaneo del abscesoguiado por TAC, tras lo cual el paciente permaneciofebril y en una nueva TAC abdominal de controlse observo la existencia de absceso residual, traslo cual se practico esplenectomia quirurgica. Desdeel segundo dia de la cirugia el paciente permanecioafebril durante toda su hospitalizacion y dos anosmas tarde permanece asintomatico.

Reverse or inverted apical ballooning in a case of refeeding syndrome

Takotsubo cardiomyopathy is characterized by the development of transient left ventricular regional wall motion abnormalities, in the absence of significant coronary artery obstruction. This syndrome usually occurs in women and is frequently associated with an intense emotional or physical stress. It usually involves apical segments, but in the recent years atypical forms have been described. Inverted or reverse Takotsubo is a variant in which the basal and midventricular segments are hypokinetic, sparing contractile function of the apex. In this report we describe the case of a 54-year-old woman, with chronic malnutrition, initially admitted because of hypoglycemia and severe electrolyte disturbance due to a refeeding syndrome. Within the next hours she experienced acute cardiac symptoms and developed heart failure with low cardiac output. Electrocardiogram (ECG), elevation of troponin and echocardiographic findings were consistent with inverted Takotsubo cardiomyopathy. To the best of our knowledge, this is the first incidence reported of inverted Takotsubo triggered by refeeding syndrome.

Valor de la angiografía rotacional radiológica intraprocedimiento en la ablación de fibrilación auricular. Comparación con otras técnicas de imagen

particular care should be taken when dressing the wound and in ensuring that the system is stably fixed in the cervical region of the patient. On the other hand, the fact that it can be connected to a permanent pacemaker generator allows for programming of more physiologic pacing modes that help to maintain the patient in a stable clinical condition and allow the patient to walk about without clinical deterioration. Such advantages are particularly desirable in patients who are totally dependent on pacing and who require very prolonged temporary pacing. The small size of the generator is conducive to portability, and this in turn helps ensure that the patient can walk around and has greater mobility in general. As a precaution, the resterilized pacemaker generators that are used for this purpose, although only ever in contact with the skin of the patient, should come from patients without evidence of infection at the time of switching to minimize the possibility of infection. The greater cost of the active fixation electrode used compared to the usual temporary pacing electrodes is compensated by the fact that the patient does not require admission to hospital in a unit with facilities for close patient monitoring. This technique should be considered in patients who will require prolonged temporary pacing for any reason, particularly those who are pacing-dependent. Miguel A. Arias,* Alberto Puchol, Marta Pachón, Jesús Jiménez-López, and Luis Rodrı́guez-Padial

Diverticulosis biventricular asociada a cardiopatía reumática: a propósito de un caso

Se presenta el caso de una mujer de 58 anos conestenosis mitral reumatica susceptible de valvuloplastiapercutanea. Un cateterismo cardiaco previorevelo la existencia de multiples diverticulos en elapex y la pared diafragmatica del ventriculo izquierdo,asi como en la pared diafragmatica delventriculo derecho. La radiografia de torax y elecocardiograma transtoracico fueron normales.Una resonancia magnetica nuclear confirmo los hallazgosdel cateterismo y descarto otras anomaliasestructurales cardiacas. Debido al posible riesgo deperforacion del ventriculo durante la valvuloplastiapercutanea, se descarto esta tecnica, realizandosefinalmente una comisurotomia mitral abierta.

Origen anómalamente alto en la pared aórtica de la arteria coronaria derecha diagnosticado mediante tomografía computarizada cardiaca multidetector

Un varón de 68 años fue remitido a nuestra institución por una estenosis aórtica sintomática para realizar sustitución valvular. Se realizó una coronariografía previamente para descartar enfermedad coronaria relevante. La coronariografía identificó un ostium de salida de la arteria coronaria derecha (ACD) localizado anormalmente alto en la pared aórtica, que obligó a una canalización no selectiva de la arteria coronaria, procedimiento que se realizó con gran dificultad. Se realizó una tomografía computarizada cardiaca multidetector (TCMD) para identificar de forma precisa el origen coronario anómalo. El origen anómalamente alto de las arterias coronarias se define como aquel que está a más de 5 o 10 mm por encima de la unión sinotubular. En nuestro caso la TCMD mostró que el ostium de la ACD se localizaba unos 20 mm por encima de la unión sinotubular adoptando en su origen un ángulo de 30° (fig. 1). La altura del origen del vaso tiene importancia ya que está en relación con el ángulo de salida de la pared aórtica y como consecuencia se ha demostrado que puede producir disminución de la perfusión coronaria. El origen de la arteria está en una cavidad sacular, como se describe en otros trabajos. La literatura refiere que esta parte de la arteria coronaria tiene una pared más delgada con la misma composición que la pared aórtica. La configuración especial del ostium coronario y su composición elástica favorecen que el ostium y, por ende, toda la arteria se mantengan abiertos durante el ciclo cardiaco. Nuestro caso tuvo un curso benigno, pero la importancia del hallazgo estriba en la información que aportó la TCMD para que el cirujano extremara las precauciones para no pinzar la aorta a este nivel o seccionar este vaso durante la cirugía.

Ectopic high origin of right coronary artery from the aortic wall diagnosed by multidetector computed cardiac tomography

A 68 year old man with symptomatic aortic stenosis was referred to our institution for aortic valve replacement. Coronary angiography had been performed to exclude significant coronary disease. The coronary angiogram identified an abnormally high ostium of the right coronary artery (RCA) which necessitated difficult nonselective catheterization. A multidetector computed cardiac tomography (MDCT) was performed to identify accurately the anomalous coronary origin. A high origin for coronary arteries has been defined as having ostia originating between 5 and 10 mm above the Sinotubular Junction (SJ). In our case, the MDCT showed the RCA was located 20 mm (mean distance) above the SJ and originated at an acute 30o angle (Figure 1) and movie. The height of the origin of the vessel was important in relation to the angle of take-off from the aortic wall since it has been postulated that a high ostium results in decreased coronary perfusion.1 The anomalous origin of this artery was a sacular cavity as described in other reports. In the literature this part of the coronary artery was thinner, similar in composition to the aortic wall. The special configuration of the coronary ostium and the elasticity of the origin of the RCA maintained patency of the artery during the cardiac cycle. The orifice was not collapsed as a slit-like ostium and there was no diastolic entrapment from the initial investment in aortic adventitia. Our case had a benign outcome, thanks to the important information derived from MDCT which allowed the cardiac surgeon to avoid accidentally cross-clamping or transecting this vessel during surgery.