Prognostic Value of Dobutamine Stress Echocardiography in Predicting Major Cardiac Events in Patients with Metabolic Syndrome.

BACKGROUND: The metabolic syndrome increases cardiovascular mortality. We report the mid-term prognostic value of dobutamine echocardiography for metabolic syndrome. PATIENTS AND METHODS: A dobutamine echocardiography protocol was performed in patients aged 18 years of age or older who suffered from chest pain and who were followed-up for two years. The patients were divided in two groups, with and without metabolic syndrome. Statistical analyses were performed using ROC curves and survival analysis; the Begg-Greenes method was used to correct for verification bias. We included 128 patients, 66 with metabolic syndrome and 62 without. RESULTS: Forty-one patients with metabolic syndrome and 36 without had positive dobutamine echocardiography test results (p = 0.77). Coronary artery disease was found in 27 patients with metabolic syndrome and in 29 without metabolic syndrome; percutaneous revascularization was required in 24 and 26 patients, respectively (p = 0.29). Cardiovascular events occurred in 28 patients during follow-up (19 in metabolic syndrome vs. 9 in non-metabolic syndrome; p = 0.17). The odds ratio of major cardiovascular events in the metabolic syndrome group was 5.8 (95% CI: 1.74-19.60); in the control group it was 8.6 (95% CI: 2.53-29.59). CONCLUSION: Dobutamine echocardiography for metabolic syndrome has high sensitivity but is not a determining factor for mid-term prognosis.

Association between depression and higher glucose levels in middle-aged Mexican patients with diabetes.

OBJECTIVE: We report an association between depression and glycemic control in patients with type 2 diabetes mellitus (DM-2). MATERIAL AND METHODS: Sixty-five diabetic patients (26 men and 39 women) aged 40-60 years were studied within 5 years of the diagnosis. The patients were assessed using the depression scale validated in Spanish, and serum glucose and glycated hemoglobin (HbA1c) levels were measured. Pearson's correlation was used to identify associations between depression and DM-2 and glycemic control; p < 0.05 was accepted as significant. RESULTS: Sex, age, anthropometric measures, and time since the diagnosis of DM-2 did not differ between patients with and without depression. CONCLUSIONS: Patients with depression had higher fasting glucose and HbA1c levels, and these levels correlated significantly with the depression score.

Telomere length and type 2 diabetes in males, a premature aging syndrome.

BACKGROUND: Increased telomere shortening has been demonstrated in several diseases including type 2 diabetes. However, it is not known whether telomere length changes during the course of type 2 diabetes. OBJECTIVE: To determine telomere length at different stages of type 2 diabetes, including early and late stages. METHODS: A total of 93 males with type 2 diabetes and 10 years or more since original diagnosis; 96 males with less than one year of diagnosis; 98 age matched healthy males. Telomere length was estimated by means of real-time polymerase chain reaction. Fasting venous blood samples were obtained for measurement of lipid peroxidation and inflammation markers. RESULTS: We found a greater telomere shortening in group (A) with type 2 diabetes of 10 years or more since original diagnosis, compared with the control group (C) of healthy males (5.4 vs 9.6 Kb) (p = 0.04) and with group B (5.4 vs 8.7 kb) (p = 0.05). With regard to inflammatory markers TNF-α, malondialdehyde peroxidation and adiponectin we found significant differences. CONCLUSION: Telomere shortening increases with the duration of diabetes. The time of exhibition suggests in parallel that the progressive increase of inflammation and/or oxidative stress plays a direct role in telomere shortening.

[Frequency and clinical outcome of odontogenic cervicofacial infection]. / Frecuencia de infección cervicofacial odontógena que requiere hospitalización.

OBJECTIVE: To measure frequency, mortality, hospitals stay and the requirement of attention in the intensive care unit (ICU) of patients with cervical infections. METHODS: A descriptive, observational and transversal study was carried out. We analyzed the database of patients admitted to Emergency Room of High Specialty Hospital, with cervical and facial infection with odontogenic origin, during a year period. RESULTS: In three cases were ambulatory and 19 where hospitalized; only three required ICU attention. The average of hospital stay was 6.3 days and the mortality of 8.3%. CONCLUSIONS: The mortality is significant in patients who require ICU and whose age is older than 60 years. Therefore this group of patients required a rapid multidisciplinary care to improve their expectations for survival expectancy.

Association between telomere length and C-reactive protein and the development of coronary collateral circulation in patients with coronary artery disease.

BACKGROUND: Coronary collateral circulation is a stabilizer factor in myocardial ischemia. We attempted to establish a link between collateral circulation, C-reactive protein (CRP), and telomere shortening. PATIENTS AND METHODS: A case-control study was performed in patients with (group A) and without (group B) coronary collaterals using coronariography. The patients were males, CRP levels and telomere length in circulating leucocytes were measured; Student t test and logistic regression were used to analyze the data. RESULTS: The study included 40 patients aged 53.9 ± 7.0 years (20 per group). Group A exhibited lower CRP levels (2.76 ± 3.34 vs 4.04 ± 3.38; P = .004); whereas telomere length was shorter in group B (2.3 ± 6.9 kb vs 6.1 ± 5.9 kb; P < .0001). CONCLUSIONS: Collateral circulation was associated with telomere shortening and elevation of CRP levels.

Pentalogía de Cantrell: actualización y nuevas perspectivas / Pentalogy of Cantrell: update and new perspectives

La pentalogía de Cantrell es una enfermedad rara, con características clínicas, anatómicas y embriológicas peculiares. Esta entidad es una variedad toracoabdominal de la ectopia cordis en la que se asocian cinco anomalías: defecto epigástrico de la línea media abdominal supraumbilical, defecto del tercio inferior del esternón, deficiencia del segmento anterior del diafragma, defectos pericárdicos y malformaciones cardíacas congénitas. La comunicación interventricular e interauricular se encuentra en la mitad de los casos y puede asociarse a otras anomalías extracardíacas como espina bífida, diversas malformaciones del sistema nervioso central, divertículo de Meckel, poliesplenia, entre otros. El diagnóstico se hace mediante ultrasonografía fetal en el primer trimestre de la gestación; en casos incompletos la tomografía helicoidal y la resonancia magnética complementan el diagnóstico. El tratamiento es quirúrgico y en varias etapas, lo primordial es proteger las vísceras expuestas y corregir la cardiopatía congénita. Los resultados aún son controversiales. El pronóstico de la enfermedad depende de la extensión del defecto, el diagnóstico temprano y el manejo perioperatorio. Nosotros consideramos que la pentalogía de Cantrell es una enfermedad compleja en la que es necesaria la intervención multidisciplinaria del equipo de salud para llegar al diagnóstico preciso y decidir el mejor tratamiento.

The pentalogy of Cantrell is a rare disease, with uniqueclinical, anatomical and embryological characteristics. This disease is a thoraco-abdominal variety of ectopia cordis. Five anomalies are associated: epigastric defect of theover umbilical abdominal mean line, defect of inferiorbreastbone third, defect of the anterior segment of the diaphragm, pericardial defects and congenital cardiac malformations. Ventricular septal defect and atrial septal defects are in half of the cases and it could be associatedto other extra cardiac anomalies as bifid spine, several malformations of central nervous system, meckeldiverticulum and polispleenia, among others. The diagnosis is made by fetal ultrasonography in the first trimesterof pregnancy. In incomplete cases, helical tomography and magnetic resonance imaging complete the diagnosis.The treatment is surgical and is carried out in severalstages. It is fundamental to protect the exposed viscera and to correct the congenital heart disease. The results still are controversial. The prognosis of the disease depends on the defect extension, time of diagnosis and peri-operative handling. We considered that the pentalogyof Cantrell is a complex pathology. A multidisciplinary health team intervention is necessary to reacha precise diagnosis and to decide the best treatment.

Improvement of diastolic function after regression of left ventricular hypertrophy / Mejora de la función diastólica tras regresión de la hipertrofia ventricular izquierda

OBJECTIVE: To evaluate the diastolic function after regression of left ventricular hypertrophy, in mild to moderate hypertension treated with angiotensin converting enzyme(ACE) inhibitor and, if necessary, with a diuretic. METHODS: Ninety-eight hypertensive patients with left ventricular hypertrophy (LVH) and abnormal left ventricle diastolic function indexes received captopril (Capotena) 50 to 200 mg/day plus chlortalidone during 12 months to reach blood pressure control, defined as a diastolic blood pressure < or =90 and systolic blood pressure < or =140 mm Hg. Left ventricular (LV) mass index was calculated by M mode and two-dimensional echocardiography, and left ventricular diastolic function was assessed by transmitral pulsed Doppler ultrasound every 3 months. RESULTS: Sixty-three patients were women and 35 were men, mean age was 53.4 +/- 8.4 years (range 34-70). Thirty-six patients had mild (36.7%) and 62 (63.3%) moderate hypertension. Treatment reduced significantly both systolic pressure from 165 +/- 13 to 137 +/- 12.9 mm Hg (p<0.05) and diastolic pressure from 99 +/- 8.6 to 86 +/- 6.37 mm Hg (p<0.05). LV mass index decreased from 155.4 +/- 32.9 to 121.7 +/- 29.14 g/m2 (p<0.05). Late diastolic filling velocity (A wave) and the ratio of E/A waves improved (p<0.05), but early diastolic filling velocity (E wave) and isovolumetric relaxation time did not change with treatment. CONCLUSIONS: Some indexes of diastolic function improved after regression of left ventricular hypertrophy and good blood pressure control with captopril and chlortalidone.

[Factors associated to heavy bleeding during heart surgery with cardiopulmonary bypass]. / Factores relacionados con hemorragia mayor durante la cirugía cardíaca bajo circulación extracorpórea.

OBJECTIVE: To evaluate the risk factors related to bleeding in patients subjected to cardiac surgery using an extracorporeal circulation pump. MATERIAL AND METHODS: A study of cases and controls was designed performed in adults, matched by age and gender with indication of elective cardiac surgery using an extracorporeal circulation pump. Those patients with hepatic failure or blood coagulation disorders were excluded. Results were analyzed by Student t test, chi-square, and logistic regression analysis, considering p values significant at <0.05. RESULTS: The patients with functional class III or IV of the CCS presented more bleeding (p = 0.006), although there were no differences when comparing the ejection fraction in both. Obesity, dyslipidemia, and arterial hypertension were identified as risk factors. The coronary artery bypass graft, multivessels bypass surgery, and prolonged surgical times are associated to the complication (p < 0.05). According to the discriminant function analysis, the cardiopulmonary derivation time, weight, aortic clamp time, and heparin doses are the factors that better discriminate the possibility of hemorrhage. CONCLUSIONS: Heavy bleeding is related to ischemic patients, longer cardiac surgery time, overweight, and heparin doses during surgery.

[Revascularization surgery through left off-pump thoracotomy is a viable alternative for coronary bypass re-operation]. / La cirugía de revascularización per toracotomía izquierda sin circulación extracorpórea, es una alternativa viable en la re-operación de puentes coronaries.

BACKGROUND: Despite substantial advances in treatment, coronary atherosclerosis is a progressive disease, for this reason a second surgery is frequent. The left anterior small thoracotomy operation on a beating heart is an alternative with less morbidity and mortality than the conventional surgery. CASES REPORT: We report two cases of coronary surgery with limited access. The first corresponds to a 72-year-old man with diabetes, hypertension, dyslipidemia, obesity, with myocardial damage and bypass surgery to anterior descendent coronary artery and first diagonal coronary artery with saphenous vein graft performed 13 years ago. Due to unstable angina and positive test for myocardial ischemia, we performed bypass surgery of minimal access to the anterior descendent coronary artery and obtuse marginal coronary artery. The second case corresponds to a man with hypertension, diabetes, obesity, previous bypass surgery of two vessels performed 4 years ago, complicated with perioperative inferior myocardial infarction. Due to unstable angina and positive test for myocardial viability, we performed a re-do coronary artery bypass graft surgery to the left anterior descending artery and first diagonal coronary arteries through a minimal access incision. In both the clinical evolution was satisfactory, they were discharged 7 days after surgery and remain asymptomatic at one year of follow-up. CONCLUSION: The antero-lateral thoracotomy off-pump coronary bypass surgery is an alternative indicated in high risk patient with coronary revascularization.

La cirugía de revascularización per toracotomía izquierda sin circulación extracorpórea, es una alternativa viable en la re-operación de puentes coronaries / Revascularization surgery through left off-pump thoracotomy is a viable alternative for coronary bypass re-operation

Despite substantial advances in treatment, coronary atherosclerosis is a progressive disease, for this reason a second surgery is frequent. The left anterior small thoracotomy operation on a beating heart is an alternative with less morbidity and mortality than the conventional surgery. CASES REPORT: We report two cases of coronary surgery with limited access. The first corresponds to a 72-year-old man with diabetes, hypertension, dyslipidemia, obesity, with myocardial damage and bypass surgery to anterior descendent coronary artery and first diagonal coronary artery with saphenous vein graft performed 13 years ago. Due to unstable angina and positive test for myocardial ischemia, we performed bypass surgery of minimal access to the anterior descendent coronary artery and obtuse marginal coronary artery. The second case corresponds to a man with hypertension, diabetes, obesity, previous bypass surgery of two vessels performed 4 years ago, complicated with perioperative inferior myocardial infarction. Due to unstable angina and positive test for myocardial viability, we performed a re-do coronary artery bypass graft surgery to the left anterior descending artery and first diagonal coronary arteries through a minimal access incision. In both the clinical evolution was satisfactory, they were discharged 7 days after surgery and remain asymptomatic at one year of follow-up. CONCLUSION: The antero-lateral thoracotomy off-pump coronary bypass surgery is an alternative indicated in high risk patient with coronary revascularization.

Factores relacionados con hemorragia mayor durante la cirugía cardíaca bajo circulación extracorpórea / Factors associated to heavy bleeding during heart surgery with cardiopulmonary bypass

OBJECTIVE: To evaluate the risk factors related to bleeding in patients subjected to cardiac surgery using an extracorporeal circulation pump. MATERIAL AND METHODS: A study of cases and controls was designed performed in adults, matched by age and gender with indication of elective cardiac surgery using an extracorporeal circulation pump. Those patients with hepatic failure or blood coagulation disorders were excluded. Results were analyzed by Student t test, chi-square, and logistic regression analysis, considering p values significant at <0.05. RESULTS: The patients with functional class III or IV of the CCS presented more bleeding (p = 0.006), although there were no differences when comparing the ejection fraction in both. Obesity, dyslipidemia, and arterial hypertension were identified as risk factors. The coronary artery bypass graft, multivessels bypass surgery, and prolonged surgical times are associated to the complication (p < 0.05). According to the discriminant function analysis, the cardiopulmonary derivation time, weight, aortic clamp time, and heparin doses are the factors that better discriminate the possibility of hemorrhage. CONCLUSIONS: Heavy bleeding is related to ischemic patients, longer cardiac surgery time, overweight, and heparin doses during surgery.

Improvement of diastolic function after regression of left ventricular hypertrophy.

OBJECTIVE: To evaluate the diastolic function after regression of left ventricular hypertrophy, in mild to moderate hypertension treated with angiotensin converting enzyme(ACE) inhibitor and, if necessary, with a diuretic. METHODS: Ninety-eight hypertensive patients with left ventricular hypertrophy (LVH) and abnormal left ventricle diastolic function indexes received captopril (Capotena) 50 to 200 mg/day plus chlortalidone during 12 months to reach blood pressure control, defined as a diastolic blood pressure < or =90 and systolic blood pressure < or =140 mm Hg. Left ventricular (LV) mass index was calculated by M mode and two-dimensional echocardiography, and left ventricular diastolic function was assessed by transmitral pulsed Doppler ultrasound every 3 months. RESULTS: Sixty-three patients were women and 35 were men, mean age was 53.4 +/- 8.4 years (range 34-70). Thirty-six patients had mild (36.7%) and 62 (63.3%) moderate hypertension. Treatment reduced significantly both systolic pressure from 165 +/- 13 to 137 +/- 12.9 mm Hg (p<0.05) and diastolic pressure from 99 +/- 8.6 to 86 +/- 6.37 mm Hg (p<0.05). LV mass index decreased from 155.4 +/- 32.9 to 121.7 +/- 29.14 g/m2 (p<0.05). Late diastolic filling velocity (A wave) and the ratio of E/A waves improved (p<0.05), but early diastolic filling velocity (E wave) and isovolumetric relaxation time did not change with treatment. CONCLUSIONS: Some indexes of diastolic function improved after regression of left ventricular hypertrophy and good blood pressure control with captopril and chlortalidone.

[Coronary artery disease in Mexican women]. / Cardiopatía isquémica en mujeres mexicanas.

OBJECTIVE: To identify differences between both genders regarding coronary artery disease occurrence. PATIENTS AND METHODS: In referred patients for cardiac catheterization we investigated coronary risk factors, clinical diagnosis, associated diseases, left ventricle ejection fraction, and coronary lesions. Data were analyzed by X2 test, Student t test, odds ratio and confidence intervals, a p value < 0.05 was considered significant. RESULTS: We studied 586 patients, 409 were men. Women were older than men (59.43 +/- 9.93 vs 56.80 +/- 10.14 years old, p < 0.05). The frequency of coronary lesions in women was 56 vs 81% in men. The proportions of positive nuclear medicine studies (14 vs 16%) and exercise treadmill test (36 vs 28%) were similar. Acute myocardial infarction was the most frequent diagnosis in men (46%) whereas in women it was angor pectoris (57%). Smoking was observed more in men (72 vs 26%) and systemic arterial hypertension in women (65 vs 48%), There were no differences in diabetes mellitus and dyslipidemia frequencies. CONCLUSION: Systemic arterial hypertension was the risk factor more frequent in women, where as in men it was smoking. Ischemia induction tests are less specific to identify coronary atherosclerosis in women. In spite of the clinical data, image and laboratory results, we had a great proportion of women without coronary lesions.

Estenosis aórtica pura y resonancia magnética en el adulto / Pure aortic stenosis and magnetic resonance in adult patients

OBJECTIVE: To evaluate the utility of the cardiovascular magnetic resonance imaging (cMRI) for quantify the aortic area in adult patients with pure aortic stenosis (AS). METHOD: Comparative cross-sectional study, blinded, in patients with AS, without another valvular pathology associated. A transthoracic echocardiogram (TTE) and cMRI were performed, in all of them. Results were analyzed by Student t test and ji-square, considering significant values p < 0.05. Bayesian analysis and ROC curve, for the determination of the disease severity. RESULTS: No were significant differences with respect to quantification of the speed of transvalvular flow between both methods (TTE 4.593 +/- 0.9114 m/s vs. cMRI 4.233 +/- 0.6894 m/s, p = 0.080), nor the ejection fraction (TTE 54.27 +/-16.451 vs. cMRI 48.40 +/-17.332, p = 0.760). The cMRI seems to underestimate the maximum and medium gradients compared with the TTE, in 12.53 mm Hg and 10.07 mm Hg respectively. The sensitivity for the diagnosis of severe aortic stenosis is 90% with specificity 80%. CONCLUSIONS: The cMRI is a useful diagnostic method for the evaluation of patients with pure aortic valve stenosis, as good as TTE. cMRI can to be a diagnostic alternative in cases with limitations to TTE.

[Cardiovascular magnetic resonance evaluation of left-to-right shunts due to cardiac septal defects in patients with pulmonary arterial hypertension]. / Resonancia magnética cardiovascular en la cuantificación de los cortocircuitos de izquierda a derecha en los defectos septales cardiacos con hipertensión arterial pulmonar.

INTRODUCTION AND OBJECTIVES: As cardiac septal defects are frequently associated with pulmonary arterial hypertension, hemodynamic assessment is essential before deciding on surgery. The aim of this study was to evaluate the use of cardiovascular magnetic resonance imaging for assessing cardiac shunts and for quantifying pulmonary artery systolic pressure in patients with cardiac septal defects. METHODS: This cross-sectional study involved patients with cardiac septal defects and clinically suspected severe pulmonary arterial hypertension who had an indication for cardiac catheterization and in whom magnetic resonance imaging was not contraindicated. Each test's results were evaluated independently by two expert radiologists and interventional cardiologists who were blinded to the results of the other test. The procedures were compared using confidence limits and intraclass correlation coefficients. RESULTS: The study involved 29 patients (18 female and 11 male) aged from 30 days to 18 years; seven had an atrial septal defect, 14 had a ventricular septal defect, and eight had an atrioventricular septal defect. The correlation coefficients for measurements made using the two procedures were 0.80, 0.75, 0.81 and 0.58 for pulmonary output, systemic output, flow ratio, and systolic pressure in the pulmonary artery, respectively. Cardiovascular magnetic resonance tended to underestimate systemic output by 0.80 L/min, pulmonary output by 1.35 L/min, left-to-right shunt flow by 0.12 L/min, and systolic pressure in the pulmonary artery by 16.5 mmHg. The complication rate with cardiac catheterization was 31% compared with 3.4% with cardiovascular magnetic resonance imaging. CONCLUSIONS: The evaluation of patients with cardiac septal defects and pulmonary arterial hypertension should initially be performed using noninvasive diagnostic techniques.

Cardiopatía isquémica en mujeres mexicanas / Coronary artery disease in Mexican women

OBJECTIVE: To identify differences between both genders regarding coronary artery disease occurrence. PATIENTS AND METHODS: In referred patients for cardiac catheterization we investigated coronary risk factors, clinical diagnosis, associated diseases, left ventricle ejection fraction, and coronary lesions. Data were analyzed by X2 test, Student t test, odds ratio and confidence intervals, a p value < 0.05 was considered significant. RESULTS: We studied 586 patients, 409 were men. Women were older than men (59.43 +/- 9.93 vs 56.80 +/- 10.14 years old, p < 0.05). The frequency of coronary lesions in women was 56 vs 81% in men. The proportions of positive nuclear medicine studies (14 vs 16%) and exercise treadmill test (36 vs 28%) were similar. Acute myocardial infarction was the most frequent diagnosis in men (46%) whereas in women it was angor pectoris (57%). Smoking was observed more in men (72 vs 26%) and systemic arterial hypertension in women (65 vs 48%), There were no differences in diabetes mellitus and dyslipidemia frequencies. CONCLUSION: Systemic arterial hypertension was the risk factor more frequent in women, where as in men it was smoking. Ischemia induction tests are less specific to identify coronary atherosclerosis in women. In spite of the clinical data, image and laboratory results, we had a great proportion of women without coronary lesions.

[Pure aortic stenosis and magnetic resonance in adult patients]. / Estenosis aórtica pura y resonancia magnética en el adulto.

OBJECTIVE: To evaluate the utility of the cardiovascular magnetic resonance imaging (cMRI) for quantify the aortic area in adult patients with pure aortic stenosis (AS). METHOD: Comparative cross-sectional study, blinded, in patients with AS, without another valvular pathology associated. A transthoracic echocardiogram (TTE) and cMRI were performed, in all of them. Results were analyzed by Student t test and ji-square, considering significant values p < 0.05. Bayesian analysis and ROC curve, for the determination of the disease severity. RESULTS: No were significant differences with respect to quantification of the speed of transvalvular flow between both methods (TTE 4.593 +/- 0.9114 m/s vs. cMRI 4.233 +/- 0.6894 m/s, p = 0.080), nor the ejection fraction (TTE 54.27 +/-16.451 vs. cMRI 48.40 +/-17.332, p = 0.760). The cMRI seems to underestimate the maximum and medium gradients compared with the TTE, in 12.53 mm Hg and 10.07 mm Hg respectively. The sensitivity for the diagnosis of severe aortic stenosis is 90% with specificity 80%. CONCLUSIONS: The cMRI is a useful diagnostic method for the evaluation of patients with pure aortic valve stenosis, as good as TTE. cMRI can to be a diagnostic alternative in cases with limitations to TTE.

[Pentalogy of Cantrell. A case report]. / Pentalogía de Cantrell. A propósito de un caso.

Ectopia cordis is an extremely rare cardiac anomaly. The heart is localized partially or totally outside the thorax cavity. This anomaly occurs as an isolated defect or combined with others midline defects. Cantrell and colleagues described, in 1958, a syndrome including defects of the abdominal wall, sternum, diaphragm, pericardium and heart. There are few successful surgical cases with this pentalogy. We describe a case with this Cantrell's pentalogy. The cardiac malformation was a univentricular heart with pulmonary stenosis. The patient underwent successful surgical palliation with a systemic-to-pulmonary anastomosis and uneventful recovering.