Echocardiographic parameters, speckle tracking, and brain natriuretic peptide levels as indicators of progression of indeterminate stage to Chagas cardiomyopathy.

BACKGROUND: Chronic Chagas cardiomyopathy (CCM) is characterized by a unique type of cardiac involvement. Few studies have characterized echocardiographic (Echo) transitions from the indeterminate Chagas disease (ChD) form to CCM. The objective of this study was to identify the best cutoffs in multiple Echo parameters, speckle tracking, and N-terminal pro B-type natriuretic peptide (NT-proBNP) to distinguish patients without CCM (stage A) vs patients with myocardial involvement (stages B, C, or D). METHODS: Cross-sectional study conducted in 273 consecutive patients with different CCM stages. Echo parameters, NT-proBNP, and other clinical variables were measured. Logistic regression models (dichotomized in stage A versus B, C, and D) adjusted for age, sex, body mass index, and NT-proBNP were performed. RESULTS: Left ventricular global longitudinal strain (LV-GLS), mitral flow E velocity, LV mass index, and NT-proBNP identified early changes that differentiated stages A vs B, C, and D. The LV-GLS with a cutoff -20.5% showed the highest performance (AUC 92.99%; accuracy 84.56% and negative predictive value (NPV) 88.82%), which improved when it was additionally adjusted by NT-proBNP with a cutoff -20.0% (AUC 94.30%; accuracy 88.42% and NPV 93.55%). CONCLUSIONS: Our findings suggest that Echo parameters and NT-proBNP may be used as diagnostic variables in detecting the onset of myocardial alterations in patients with the indeterminate stage of ChD. LV-GLS was the more accurate measurement regarding stage A differentiation from the stages B, C, and D. Prospective longitudinal studies are needed to validate these findings.

Matrix metalloproteinases 2 and 9 as diagnostic markers in the progression to Chagas cardiomyopathy.

BACKGROUND: Infection with the Trypanosoma cruzi parasite is endemic in parts of Central and South America. Approximately 30% of those infected develop Chagas cardiomyopathy, the most common cause of heart failure in this region. No suitable biomarker is available that reflects the evolution of the disease. Although there is substantial evidence of a strong inflammatory reaction following infection that could activate matrix metalloproteinases (MMPs), their role in the development of Chagas cardiomyopathy is unknown. METHODS: A cross-sectional study was conducted in Bucaramanga, Colombia, from 2002 to 2006, including 144 patients at different stages of Chagas disease and 44 control patients. The potential enzyme activities of MMP-2 and MMP-9 in plasma samples were determined by gelatin zymography. Clinical data including T cruzi serology, electrocardiograms, and echocardiograms were recorded for all patients. RESULTS: Densitometric analysis of potential enzyme activities in plasma samples showed a significant increase of 72-kd MMP-2 (P < .001) and 92-kd MMP-9 (P < .001) in T cruzi seropositive patients compared with control subjects. Matrix metalloproteinase 9 showed significantly increased activity in patients with abnormal electrocardiogram (P < .004) and with dilated cardiomyopathy compared (P < .001) with controls. Analysis of the MMP-2 and MMP-9 results in relation to clinical data revealed that abnormal heart relaxation correlated positively with high MMP-2 levels in patients with dilated cardiomyopathy (r = 0.75, P < .01). CONCLUSIONS: Plasma MMP-2 and MMP-9 both appear to be useful biomarkers for detecting the advent and progression of cardiomyopathy in T cruzi-infected individuals.

Longitudinal strain by speckle tracking and echocardiographic parameters as predictors of adverse cardiovascular outcomes in chronic Chagas cardiomyopathy.

To analyze the prognostic value of left ventricular global longitudinal strain (LV-GLS) and other echocardiographic parameters to predict adverse outcomes in chronic Chagas cardiomyopathy (CCM). Prospective cohort study conducted in 177 consecutive patients with different CCM stages. Transthoracic echocardiography measurements were obtained following the American Society of Echocardiography recommendations. By speckle-tracking echocardiography, LV-GLS was obtained from the apical three-chamber, apical two-chamber, and apical four-chamber views. The primary composite outcome (CO) was all-cause mortality, cardiac transplantation, and a left ventricular assist device implantation. After a median follow-up of 42.3 months (Q1 = 38.6; Q3 = 52.1), the CO incidence was 22.6% (95% CI 16.7-29.5%, n = 40). The median LV-GLS value was - 13.6% (Q1 = - 18.6%; Q3 = - 8.5%). LVEF, LV-GLS, and E/e' ratio with cut-off points of 40%, - 9, and 8.1, respectively, were the best independent CO predictors. We combined these three echocardiographic markers and evaluated the risk of CO according to the number of altered parameters, finding a significant increase in the risk across the groups. While in the group of patients in which all these three parameters were normal, only 3.2% had the CO; those with all three abnormal parameters had an incidence of 60%. We observed a potential incremental prognostic value of LV-GLS in the multivariate model of LVEF and E/e' ratio, as the AUC increased slightly from 0.76 to 0.79, nevertheless, this difference was not statistically significant (p = 0.066). LV-GLS is an important predictor of adverse cardiovascular events in CCM, providing a potential incremental prognostic value to LVEF and E/e' ratio when analyzed using optimal cut-off points, highlighting the potential utility of multimodal echocardiographic tools for predicting adverse outcomes in CCM.

Plasma nitrate levels and flow-mediated vasodilation in untreated major depression.

OBJECTIVE: Findings from several studies have revealed that major depression is associated with an increased cardiovascular risk. The physiopathologic mechanisms of this association remain unclear, although recently, it has been hypothesized that a decreased production of nitric oxide could be a potential contributor to vascular dysfunction in depressive patients. The objective of this study was to evaluate nitric oxide production and vascular endothelial function in treatment-naive young healthy adults with a first episode of major depression. METHODS: A case-control study in 50 treatment-naive young adults with a first episode of major depression and 50 healthy control subjects was conducted. Plasma levels of nitric oxide metabolites (nitrates/nitrites) were determined using a colorimetric assay based on Griess reaction. Endothelial function was assessed by flow-mediated vasodilation measurements after reactive hyperemia. RESULTS: The mean age of the depressed patients was 22.6 (standard deviation [SD], 4.6) years, whereas the controls were 23.4 (SD, 4.8) years. Sixteen men (32%) and 34 women (68%) were included in each group. The plasma nitrite/nitrate concentrations were significantly lower in depressive subjects compared with healthy controls (17.5 [SD, 4.9] µmol/L versus 21.6 [SD, 7.0] µmol/L, p < .001); however, flow-mediated vasodilation values were similar in both groups (13.1% [SD, 4.3%] versus 12.1% [SD, 5.0%], p = .10). CONCLUSIONS: Decreased plasma concentrations of nitric oxide metabolites are not associated with vascular endothelial dysfunction in young subjects with a first episode of major depression. Reduced nitrate/nitrite levels could reflect a decreased nitric oxide production in the central nervous system of depressed subjects. Further studies are needed to confirm this hypothesis.

Inflammation but not endothelial dysfunction is associated with the severity of coronary artery disease in dyslipidemic subjects.

INTRODUCTION: Endothelial dysfunction and inflammation play a key role in the development of atherosclerosis. The present study evaluated endothelial function, inflammatory parameters, and carotid intima-media thickness (IMT) in dyslipidemic patients with or without coronary artery disease (CAD). METHODS: Metabolic profile and inflammatory parameters were determined in dyslipidemic patients with (+CAD, n = 33) and without (-CAD, n = 69) symptomatic CAD. Endothelial function was evaluated by flow mediated dilatation (FMD) and plasma concentration of nitrites and nitrates. Carotid IMT was measured by ultrasound. RESULTS: No significant differences were observed in anthropometric hemodynamic or metabolic parameters between the groups. After adjusting by age and medication usage, some inflammatory markers were significantly higher in +CAD; however no significant differences in FMD or plasma levels of nitrites were observed. CONCLUSIONS: In subjects with dyslipidemia, the presence of CAD is associated with an elevation of certain inflammatory markers and carotid IMT but not with further endothelial dysfunction.

Raised C-reactive protein and impaired flow-mediated vasodilation precede the development of preeclampsia.

BACKGROUND: The aim of this study was to investigate whether impaired flow mediated vasodilation precedes the clinical manifestations of preeclampsia and whether is associated with inflammation. METHODS: We conducted a nested case-control study in a prospective cohort of 506 normotensive women recruited before the 30th week of gestation (mean gestational age of 21.8 weeks). At enrollment, flow-mediated dilation was measured in the brachial artery using a 7.5-MHz transducer. C-reactive protein plasma concentrations and leukocyte count were also determined at study entry. Patients were followed until delivery, and medical records were reviewed for each patient to confirm the presence or absence of preeclampsia or gestational hypertension. RESULTS: Of the women studied, 14 developed preeclampsia, 18 developed gestational hypertension, and 474 remained normotensive. Two normotensive pregnant control subjects were randomly selected for each case, matched by maternal age, gestational age, and body mass index at enrollment. Women who subsequently developed preeclampsia had lower flow-mediated dilation (13.4% +/- 4.3% v 18.2% +/- 7.2, P = .026), higher C-reactive protein plasma concentrations (8.7 +/- 5.5 mg/dL v 5.3 +/- 4.3 mg/dL, P = .022) and leukocyte count (10.3 +/- 2.0 x 10(9)/L v 9.1 +/- 2.0 x 10(9)/L, P = .036) at study entry. CONCLUSIONS: Decreased flow-mediated vasodilation and higher levels of CRP are present in early stages of gestation in women who subsequently develop preeclampsia. These alterations occur before the onset of clinical symptoms of PE. Further studies are needed to confirm that flow-mediated dilation and C-reactive protein could be useful methods to screen women at risk of developing preeclampsia.

Valve in valve en posición tricuspídea: reconociendo opciones de manejo para la válvula «olvidada¼ / Valve in valve in tricuspid position: recognizing management options for the "forgotten" valve

Resumen Presentamos el caso de una paciente con bioprótesis tricuspídea disfuncionante a quien se le realizó un implante valve in valve con una prótesis transcatéter SAPIEN XT, demostrando que esta técnica es una alternativa terapéutica válida frente a la reintervención de la válvula tricúspide.

Abstract We present the case of a patient who was implanted with a transcatheter prosthesis on a dysfunctional bioprosthesis, demonstrating that it is a valid therapeutic alternative to reoperation in those patients with high surgical risk.

Gran masa intracardiaca como causa de disnea y palpitaciones en mujer joven que acude a urgencias / Large intra-cardiac mass as a cause of dyspnoea and palpitations in a young woman seen in an emergency department

Resumen Los tumores cardíacos primarios son poco frecuentes y a menudo asintomáticos. Tienen una incidencia que varía de 0,0017% a 0,28%. El diagnóstico diferencial de masas cardíacas incluye vegetaciones, trombos y tumores. Puede involucrar el endocardio, miocardio o epicardio. La afectación secundaria del corazón por tumores extracardíacos es rara. Los tumores benignos constituyen el 80% de las neoplasias cardíacas primarias y los mixomas son el tipo predominante. El tumor cardíaco maligno más frecuente es el angiosarcoma, y se caracteriza por crecimiento rápido, invasión local y metástasis a distancia. Se presenta el caso de paciente adulta joven con síntomas cardiovasculares inespecíficos asociados a pérdida de peso, cuyo diagnóstico ecocardiográfico e histopatológico es compatible con mixoma cardíaco.

Abstract Primary cardiac tumours are rare and are often asymptomatic, with an incidence that varies from 0.0017% to 0.28%. The differential diagnosis of cardiac masses includes, growth, clots, and tumours. It can involve the endocardium, myocardium or epicardium. The secondary involvement of the heart due to extra-cardiac tumours is rare. Benign tumours make up 80% of the primary cardiac neoplasms, and myxomas are the most predominant type. The most common malignant cardiac tumour is the angiosarcoma, and is characterised by rapid growth, local invasion, and distant metastases. A case is presented of a young adult patient, with non-specific cardiovascular symptoms together with a loss of weight. Her echocardiographic and histopathology diagnosis was compatible with a cardiac myxoma.

Hyperinsulinemia is a predictor of new cardiovascular events in Colombian patients with a first myocardial infarction.

BACKGROUND: Acute Myocardial Infarction (AMI) is one of the main causes of mortality and disability in Colombia. The factors associated to a new event in surviving subjects to a first AMI in our population have not yet been fully identified. METHODS: Two hundred and ninety five surviving subjects to a first AMI (58.8±12.6 years) were included in a prospective cohort study between 2000 and 2006. Lipid profile, glycemia and plasma insulin levels were measured. Deaths of cardiovascular origin, a new AMI, unstable angina, heart failure, stroke, new myocardial revascularization or angioplasty were considered new cardiovascular events. RESULTS: The study included 61 (20.6%) women and 234 (79.4%) men. The mean follow up time was 50±30 months with a 38.9% incidence of new events. Fifty five patients (18.6%) were diabetic. Bi-varied analysis identified as risk factors for a new cardiovascular event the presence of: hypertension, anterior descending coronary artery stenosis, intrahospital cardiac failure, age over 55, low income, lack of education, Killip III-IV, heart rate over 76 bpm, pulse pressure over 80 mmHg, total cholesterol over 200 mg/dl and insulin over 10 IU/ml. After logistic regression analysis, the log values of insulin remained as the only significant predictor for new cardiovascular events. CONCLUSIONS: Hyperinsulinism was the most important factor associated to the occurrence of new cardiovascular events in Colombian patients with AMI, which emphasizes the pivotal role of insulin resistance in the physiopathologic mechanisms of atherosclerosis, especially in undeveloped countries.

Papel del óxido nítrico en la fisiología normal de la vía aérea y sus implicaciones en la fisiopatología de la hipertensión pulmonar / The role of nitric oxide (no) in the normal physiology of the airway and its implications on the pathophysiology of pulmonary hypertension / Papel do óxido nítrico na fisiología normal da via aérea e seus implicações na fisiopatología da hipertensão pulmonar

La hipertensión pulmonar es una patología de la microvasculatura pulmonar, caracterizada por un estado de vasoconstricción, proliferación endotelial, proliferación de músculo liso y trombosis. Se han implicado diversas moléculas en su etiología, demostrándose una producción elevada de agentes vasoconstrictores, mitogénicos, protrombóticos y mediadores proinflamatorios como tromboxano A2, endotelina (ET), el inhibidor del activador del plasminógeno y una menor producción de sustancias vasodilatadoras como la prostaciclina (PGI2) y el óxido nítrico (ON), que en condiciones fisiológicas actúa modulando el tono basal de los vasos pulmonares y también como mediador inflamatorio e inmunomodulador. La histopatología de las lesiones en la hipertensión pulmonar sugiere que el daño en el endotelio y los estímulos proliferativos son procesos fundamentales de su desarrollo, desencadenados por alteraciones en la producción o en la actividad del ON, ocasionados por acumulación de radicales libres que lleva a menor biodisponibilidad del ON. En el presente artículo se revisa el papel que juega el ON en la fisiología normal de la vía aérea y sus implicaciones en la fisiopatología de la hipertensión pulmonar...

Pulmonary hypertension is a disease of the pulmonary microvasculature characterized by vasoconstriction, smooth muscle and endothelial proliferation, and thrombosis. Many molecules have been implicated in the etiology, demonstrating an increased production of vasoconstrictor agents as well as mitogenic, prothrombotic and inflammatory mediators such as tromboxano A2, endothelin (ET), and the inhibitor of the plasminogen activator, together with a low production of vasodilator substances such as prostacyclin (PGI2) and nitric oxide (NO), which in physiological conditions, acts as a modulator of the basal tones of the pulmonary vessels, an inflammatory mediator, and an immunomodulator. The histopathology of the injuries in pulmonary hypertension, triggered by the alteration in the production or activity of NO, which is caused by an accumulation of free radicals that leads to lower bioavailability of NO, suggests that the damage in the endothelium and the proliferative stimulus are fundamental processes for their development. This article reviews the role played by NO in the normal physiology of the airway and its implications on the pathophysiology of pulmonary hypertension...

A hipertensão pulmonar é uma patologia da microvasculatura pulmonar, caracterizada por um estado de vasoconstrição, proliferação endotelial, proliferação de músculo liso e trombose. Implicaram-se diversas moléculas na sua etiologia, demonstrando-se uma produção elevada de agentes vasoconstrictores, miogênicos, pro trombóticos e mediadores proinflamatorios como tromboxano A2, endotelina (ET), o inhibidor do ativador do plasminógeno e uma menor produção de substâncias vasodilatadoras como a prostaciclina (PGI2) e o óxido nítrico (ON), que em condições fisiológicas atua modulando o tom basal dos copos pulmonares e também como mediador inflamatório e inmunomodulador. A histopatológica das lesões na hipertensão pulmonar sugere que o dano no endotélio e os estímulos proliferativos são processos fundamentais de seu desenvolvimento, desencadeados por alterações na produção ou na atividade do ON, ocasionados por acumulação de radicais livres que leva a menor biodisponibilidade do ON...

La velocidad de propagación del flujo M color es un marcador sensible de disfunción diastólica en miocardiopatía chagásica / Color M flow velocity propagation is a sensible diastolic disfunction marker in Chagas cardiomyopathy

Introducción y objetivos: la miocardiopatía de origen chagásico es un problema grave de salud en América Latina. En Colombia es la primera causa de miocardiopatía dilatada de origen infeccioso. Los cambios que se describen en la evaluación de la función diastólica de los pacientes con miocardiopatía, son precoces y en general preceden a los síntomas y a los cambios en la función sistólica. El objetivo de este estudio es conocer el comportamiento de las distintas variables para evaluar la función diastólica en pacientes en diferentes estadios clínicos de la enfermedad de Chagas, y establecer si existen alteraciones tempranas que puedan predecir el grado de progresión de la enfermedad.Métodos: se valoró la función ventricular sistólica y diastólica en 600 pacientes distribuidos así: 165 (27,5 porciento) asintomáticos seronegativos para enfermedad de Chagas (grupo 0); 277 (46,2 porciento) asintomáticos seropositivos (grupo I); 116 (19,3 porciento) seropositivos con bloqueo de la rama derecha del haz de His (grupo II) y 42 (7 porciento) seropositivos con insuficiencia cardiaca (grupo III). Se registraron las medidas de flujo mitral y tricúspide, venas pulmonares, Doppler del anillo mitral y tricúspide, velocidad de propagación del flujo M color e índice de Tei. Para estimar la diferencia de los grupos clínicos se usó el grupo 0 como referencia...

Tratamiento de aorta abdominal e ilíacas con técnica endovascular / Treatment of abdominal aorta and iliac arteries with endovascular technique

Antecedentes: desde 1991 la técnica endovascular se ha aplicado con éxito en el manejo de los aneurismas de aorta infrarrenal, y se ha perfeccionado de manera tal que rápidamente se ha convertido en una alternativa para pacientes de alto riesgo para la cirugía convencional. Objetivo: describir los resultados institucionales en el manejo de las patologías de aorta abdominal e ilíacas mediante técnica endovascular desde 2003 a 2005.Diseño-Método: estudio descriptivo, longitudinal, retrospectivo, en el que se analizaron las historias clínicas de los pacientes sometidos a procedimiento endovascular de aorta abdominal e ilíacas. El análisis se realizó en Stata 8,0 S/E...

Antecedents: since 1991 endovascular technique has been successfully used in the management of infra-renal aortic aneurysms and it has been improved in such a way that it has quickly turned into an alternative for patients considered having high risk for conventional surgery. Objective: describe the institutional results in the management of abdominal aortic pathologies through endovascular technique from 2003 to 2005. Design-Method: descriptive, longitudinal, retrospective study in which clinical histories of patients that underwent an endovascular procedure of abdominal aorta and iliac arteries were analyzed. The analysis was performed in Stata 8,0 S/E. Results: 9 patients received exclusively treatment for abdominal aortic and iliac lesions. All were male individuals with mean age 68.9 ± 8.1 years. 6 patients had diagnosis of infra-renal aortic aneurysm and the other 3 had anastomotic aneurysms. Requirement of endoprosthesis was evidenced in an average of 1.9 ± 0.8. Femoro-femoral bypass surgery was performed as simultaneous procedure in 4 of the 9 patients. 77.8% of patients had no complications. Mortality due to the procedure was 22% (2 patients) and it is important to notice that only these 2 patients had complications. Conclusions: exclusion of aortic and iliac aneurysms with modular endoprosthesis is being widely implemented as a valid treatment option, with excellent results that avoid the risks of conventional surgery and its associated morbidity.

Experiencia en el manejo endovascular para el tratamiento de la aorta torácica / Experience in endovascular management for thoracic aorta treatment

Antecedentes: el tratamiento endovascular ofrece la posibilidad de cubrir el origen de la disección y evitar que progrese hasta aneurisma de la aorta, y con ello demuestra una reducción en la mortalidad hasta del 16 porciento.Objetivo: evaluar los resultados quirúrgicos en términos de morbi-mortalidad de los pacientes sometidos a manejo endovascular de las lesiones de la aorta torácica en la Fundación Cardiovascular de Colombia desde 2003 hasta 2005. Diseño–método: estudio longitudinal tipo descriptivo retrospectivo, en el que se evaluaron las historias clínicas de todos los pacientes sometidos a manejo endovascular de patología toracoabdominal; en éste sólo se incluyeron los pacientes con procedimientos de la aorta torácica, desde 2003 hasta 2005. El análisis de los datos se realizó en Stata/SE 8,0...

Utilidad de la ecocardiografía transesofágica en el manejo intervencionista de las patologías cardiacas / Utility of transesophageal echocardiography in the interventionist management of heart pathologies

La ecocardiografía transesofágica ha tenido un importante desarrollo en los últimos años, lo que ha permitido un amplio uso, así como una mayor definición de las estructuras y funcionalidad del corazón y de los grandes vasos. En este artículo se hace una breve descripción del apoyo de este método diagnóstico en el manejo intervencionista de patologías como la estenosis mitral, la comunicación interauricular y la disección aórtica, en la Fundación Cardiovascular de Colombia durante los últimos años. La cirugía ya no es el método a utilizar en algunas de ellas, con lo que la morbilidad, la estancia intrahospitalaria y la incapacidad se reducen de manera considerable.

Transesophageal echocardiography has had an important development in the last years, allowing its wide use, and a better definition of the structure and functionality of the heart and great vessels. In this article we make a short description of this diagnostic method in the interventionist management of pathologies such as mitral stenosis, atrial septal defect and aortic dissection in the Colombian Cardiovascular Foundation during the last years. Surgery is not the method to use in some of them now, so that morbidity, intrahospital stay and incapacity are considerably reduced.

Función diastólica en sujetos con serología positiva para enfermedad de Chagas procedentes del estudio CHICAMOCHA / Diastolic function in subjects with positive Chagas’ disease serology from the Chicamocha study

Se presenta un estudio ecocardiográfico en 430 donantes de banco de sangre, de los cuales 120 fueron negativos para Trypanosoma cruzi (controles), 231 fueron seropositivos sin cambios en el electrocardiograma (estadio I) y 79 fueron seropositivos con cambios en el electrocardiograma (estadio II). Se estudió la función diastólica y, a través del flujo mitral, se encontró un aumento significativo de la velocidad de la onda A con relación al grupo control (54 vs. 50,5 cm/seg). Con relación al flujo de las venas pulmonares, no hubo cambios significativos en las velocidades sistólicas pero sí aumento de las velocidades diastólicas de los sujetos estadio II con relación a los controles (48,7 vs. 46,7 cm/seg). El parámetro más significativo se halló en la duración de la onda A de las venas pulmonares, la cual aumentó en los sujetos estadio I y mucho más en los sujetos estadio II (0,13 seg para el grupo control, 0,14 seg para el grupo estadio I y 0,15 seg respectivamente). La diferencia entre la duración de la onda A mitral y la duración de la onda A de las venas pulmonares, mostró menor significancia en los sujetos estadio I y mayor aún (resultado negativo) en los sujetos estadio II, expresando así un aumento de la presión capilar pulmonar de estos últimos (control 0,012 seg, estadio I 0,009 seg y estadio II-0,007). La relación entre la duración de la onda A de las venas pulmonares y de la onda A mitral (Ap/Am), mostró, igualmente, un aumento progresivo con respecto a los controles (control 0,94, estadio I 0,96 y estadio II 1,08). El tiempo de relajación isovolumétrica aumentó significativamente en los sujetos estadio II con relación al grupo control (0,084 seg vs. 0,076 seg). En lo que concierne a las velocidades del anillo mitral, se encontró un aumento significativo en la velocidad de la onda A en los sujetos estadio II con respecto a los controles (17,9 cm/seg vs. 15,9 cm/seg). No hubo diferencias significativas en la velocidad sistólica ni en la velocidad de la...

An echographic study of 430 blood bank donors is presented. 120 were negative for Trypanosoma cruzi (controls), 231 were serum-positive without changes in the electrocardiogram (state I) and 79 were positive with electrocardiographic changes (state II). The diastolic function was studied and through the mitral flow a significant increase in the A wave velocity in relation to the control group, was found (54 vs. 50.5 cm/s). In relation to the pulmonary veins’ flow, there were no significant changes in the systolic velocities but there was an increase in the diastolic velocity in state II subjects (48.7 vs. 46.7 cm/s). The most signifying parameter was that of the pulmonary veins’ A wave duration, that increased in state I subjects and even more in state II subjects (0.13 s for the control group, 0.14 s for state I group and 0.15 s for state II, respectively). The difference between the duration of the mitral A wave and the duration of the pulmonary veins’ A wave showed less significance in state I subjects and even less (negative) in state II subjects, expressing in this way an increment in pulmonary capillary tension in these last ones (control: 0.012 s, state I: 0.09 s and state II: 1.08 s). The relation between the pulmonary veins’ A wave and that of the mitral A wave (Ap/Am) showed a progressive increment as well, in regard to the control group (17.9 cm/s vs. 15.9 cm/s). There were no significant differences in the systolic velocity, or in the velocity of the E ring wave. When observing the M-colour flow propagation behaviour, a significant decrease was noticed in state I subjects and even more in state II subjects in relation to the control group (72.7, 66.8 and 62.6 cm/s respectively).

Manejo endovascular de la aorta torácica / Endovascular treatment of thoracic aorta

En comparación con el tratamiento convencional, la terapia endovascular en aneurisma de aorta torácica, presenta los mejores resultados, por lo que se convierte en el tratamiento de elección para la patología de aorta torácica descendente endovascular, por su baja morbimortalidad perioperatoria. El tratamiento quirúrgico por vía retroperitoneal y/o endovascular para aneurisma de aorta abdominal infrarrenal, resulta ser especialmente seguro en pacientes octogenarios o con alta morbilidad. Esta cohorte institucional presenta resultados perioperatorios y en el seguimiento, similares a los reportados en la literatura mundial.

Compared with the conventional treatment, endovascular therapy in thoracic aortic aneurysm shows the best results, being the election treatment for the pathology of the descending thoracic aorta, due to its low peri-operative morbid-mortality. Surgical treatment by retro-peritoneal route and/or endovascular for infra-renal abdominal aortic aneurysm is especially safe in octogenarian patients or in those with a high mortality rate. This institutional cohort show peri-operative and follow-up results similar to those reported in the world literature.

Arteria carótida y placa carótida un órgano / Carotid artery and plaque. Carotid: an organ

En estos momentos es posible hacer recomendaciones sobre las indicaciones de la endarterectomía carotídea, basadas en los ensayos clínicos publicados y en la revisión de grandes series quirúrgicas. Las indicaciones para la cirugía dependerán del grado de estenosis y de la morfología de la placa, así como del estado clínico del paciente y de la morbi-mortalidad del equipo quirúrgico. Este al igual que otros estudios con grandes series de casos, evidencia que la endarterectomía carotídea y/o el manejo endovascular, realizado por equipos expertos, es un procedimiento seguro en pacientes con indicación quirúrgica.

It is now possible to recommend indications for aortic endarterectomy, based on published clinical essays and revision of large surgical series. Surgery indications will depend on the stenosis degree and the plaque morphology, as well as on the patient's clinical state and the morbid-mortality in this surgical team. As other studies with large case series, evidences that carotid endarterectomy and/or endovascular management, when realized by expert teams, is a safe procedure in patients with surgical indication.

Endarterectomía carotídea en pacientes sintomáticos y asintomáticos: resultados de morbi-mortalidad desde 1998 hasta 2005 / Carotid endarterectomy in symptomatic and asymptomatic patients: morbid-mortality results from 1998 to 2005

Antecedentes: el accidente cerebrovascular es la tercera causa de muerte y probablemente la causa más importante de discapacidad a largo plazo. La tasa de mortalidad está entre 15% y 35% con el primer ataque y se eleva a 65% para los accidentes cerebrovasculares subsiguientes. Los resultados a largo y mediano plazo avalan esta técnica quirúrgica para el tratamiento de la enfermedad carotídea, al demostrar altos perfiles de seguridad. Objetivo: determinar los resultados de morbilidad y mortalidad quirúrgica y a 3, 6 y 12 meses de seguimiento, en los pacientes sometidos a endarterectomía carotídea desde 1998 hasta septiembre de 2005. Diseño-método: se evaluaron las historias clínicas de los pacientes sometidos a endarterectomía carotídea, desde 1998 hasta septiembre de 2005. Resultados: se realizaron 42 procedimientos desde 1998 hasta septiembre de 2005; el 57% de los pacientes eran hombres, con edad promedio de 68,8 ± 9,9 años. Los antecedentes de importancia fueron: hipertensión arterial (82%), tabaquismo (61%) y dislipidemia (50%). El 82% de los pacientes mostraban síntomas de enfermedad carotídea. Once pacientes tuvieron lesión de carótida derecha, 16 de carótida izquierda y 15 lesión bilateral, con un promedio de obstrucción de 85 ± 11,4%. La mortalidad fue de 4,7% y no estaba relacionada con el procedimiento quirúrgico. A septiembre de 2005 el 57% de los pacientes egresados estaban libres de síntomas. Conclusiones: la mortalidad para este grupo de pacientes es comparable con los resultados publicados en todo el mundo. La seguridad del procedimiento avala esta técnica quirúrgica como la primera opción en el manejo de la patología carotídea.

Antecedents: cerebrovascular disease is the third cause of death and probably the most common cause of significant long term disability. Mortality rate with first stroke is between 15% and 35% and goes up to 65% with subsequent strokes. Results at long and middle term endorse carotid endarterectomy for carotid artery disease treatment by demonstrating high safety profiles. Objective: to determine the surgical morbidity and mortality results at 3, 6 and 12 months of follow-up in patients submitted to carotid endarterectomy from 1998 to 2005. Design-Method: clinical histories of patients submitted to carotid endarterectomy from 1998 to September 2005 were evaluated. Results: 42 procedures were realized since 1998 until September 2005. 57% of the patients were men with mean age 68.8 ± 9.9 years. Important antecedents were arterial hypertension (82%), cigarette smoking (61) and dyslipidemia (50%). 82% showed symptoms of carotid disease. 11 patients had right carotid lesion and in 15 the lesion was bilateral, with mean obstruction of 85 ± 11.4%. Mortality was 4.7% and was not related to the surgical procedure. At September 2005, 57% of the discharged patients were asymptomatic. Conclusions: mortality for this group of patients is comparable to the worldwide published results. Procedure safety guarantees this surgical technique as the first option in this carotid pathology management.

Ecocardiografía Trasesofágica

La Ecocardiografía Trasesofágica es una nueva técnica que ofrece imágenes de ultrasonido de las estructuras cardíacas y de los grandes vasos desde el esófago retrocardiaco. Aunque la Ecocardiografía Bidimensional Trastorácica con dopler color y dopler de onda continua y pulsada revolucionó la evaluación no invasiva de las estructuras anatómicas y los trastornos funcionales del corazón y de los grandes vasos, en muchos casos se presentaba seria limitación dada fundamentalmente por la atenuación acústica de las estructuras del tórax: Pulmón, tejido subcutáneo, costilla; del corazón: Materiales de las prótesis valvulares, calcificación de las válvulas nativas, etc. Es en estos pacientes en donde la Ecocardiografía Trasesofágica constituye un valioso método diagnóstico pues logra eliminar la causa de la interferencia en la pared torácica. De otro lado algunas estructuras que son visualizadas pobremente por la Ecocardiografía Bidimensional Trastorácica, son mejor evaluadas por la Ecocardiografía Trasesofágica: Area de las aurículas, prótesis valvulares, arteria coronaria proximal, aorta torácica y septum interauricular

Manifestaciones otorrinolaringológicas del síndrome de inmunodeficiencia adquirida / Otorhinolaryngologic manifestations of acquired immunodeficiency syndrome

El síndrome de inmunodeficiencia adquirida (SIDA), una de las enfermedades más estudiadas y discutidas en los ultimos 10 años, fué reconocida por primera vez en 1981 pero fué hasta 1983 cuando se identificó el agente causal. En general, la inmunodeficiencia consiste en una desminución del número y función de los linfocitos T cooperadores y en un aumento de los citotóxicos. Se ha informado en la literatura que alrededor del 40% de los pacientes con Síndrome de Inmunodeficiencia Adquirida tiene manifestaciones en cabeza y cuello en algún momento del curso de esta patología. En el presente estudio se revisaron 293 expedientes de pacientes con diagnóstico de Síndrome de Inmunodeficiencia Adquirida atendidos en el Instituto Nacional de la Nutrición Salvador Zubirán, para identificar la incidencia de lesiones en cabeza y cuello asociados al síndrome. La frecuencia encontrada en el presente estudio fué mayor que en otras series (88 por ciento y 41 por ciento). Las áreas afectadas en orden de frecuencia fueron las siguientes: cavidad oral, orofaringe, nariz y senos paranasales, piel de cabeza y cuello, oído medio, laringe, oído externo y glándulas salivales en relación con diagnósticos como candidiasis orofaríngea en primer lugar, sinusitis, sarcoma de Kaposi en cabeza y cuello, otitis media aguda, laringitis y otitis externa. El conocimiento de estas manifestaciones permitirán un mejor estudio de cada patología en beneficio de los pacientes.