Public insurance program impact on catastrophic health expenditure on acute myocardial infarction.

OBJECTIVE: ST-segment elevation myocardial infarction (STEMI) has an important economic burden that poised the urgent need to evaluate its catastrophic medical expense. This study evaluates the first 5 years of the national health initiative called Popular Insurance (PI) at the National Institute of Cardiology in Mexico. STUDY DESIGN: Retrospective data analysis. METHODS: STEMI patients with (n=317) and without (n=260) PI were selected. Analysed variables included socio-economical context, management care, cost evaluation and three outcomes (mortality, hospital readmission and therapeutic adherence). Descriptive statistical analyses, Kaplan-Meier survival and Support Vector Machine models were used accordingly. RESULTS: Treatment costs were higher for PI-covered individuals (P=0.022) and only 1.89% of them remained in debt, in contrast to 16.15% of those without PI. Statistically significant differences were found in relation to days in hospital wards (P<0.001), imaging studies (P<0.001) and surgical materials (P=0.04). Survival analysis (P=0.44) and therapeutic adherence (P=0.38) showed no differences. Hospital readmission was predicted with an 81.97% accuracy. The most important predictive variables included were stent type, number of days at the coronary care unit and hospital wards. CONCLUSIONS: The PI has proven to be a successful program where no differences were found in terms of health care and survival, whereas it provides timely financial support for families facing catastrophic health challenging events.

Levels of uric acid may predict the future development of pulmonary hypertension in systemic lupus erythematosus: a seven-year follow-up study.

OBJECTIVE: The objective of this paper is to assess whether pulmonary hypertension (PH) may be detected at one point in time or longitudinally predicted by serum uric acid (sUA) levels in systemic lupus erythematosus (SLE). METHODS: We conducted a post-hoc analysis of a long-term followed cohort of Mexican SLE patients. Echocardiography-based definitions of PH by the ESC/ERS/ISHLT and its associations with clinical and laboratory data on enrollment were studied. Especially, the impact that sUA levels at baseline may have on the future development of PH in patients with normal pulmonary artery systolic pressure (PASP) was explored. RESULTS: Out of the 156 SLE patients originally enrolled in the cohort, 44 met the inclusion criteria for the present study and were grouped as having (n =10) or not having (n = 34) PH. At baseline, sUA levels of 5.83 ± 1.79 and 5.82 ± 1.97 mg/dl (p = ns) were found in patients with and without PH, respectively. No association between PASP and other markers was found. In patients with normal PASP, the presence of sUA ≥ 7 mg/dl at baseline predicted future development of PH (relative risk 8.5, 1.0009 to 72; p = 0.04). CONCLUSION: In SLE, sUA levels at one point in time are useless to detect PH. However, steady hyperuricemia may predict the future development of PH in patients with normal PASP at baseline.

Cryptogenic stroke in young patients: long-term prognosis and recurrence.

BACKGROUND: Around 40% of strokes in young people are labelled as infarcts of undetermined cause. The aim of this study was to determine the image characteristics, the long-term functional outcome and recurrence after cryptogenic ischaemic stroke. METHODS: We studied ninety-eight patients under 45 years of age during a median follow up of 54 months (range 12-238), with ischaemic stroke of undetermined cause. We registered vascular risk factors, clinical syndrome, laboratory and imaging results. We used Rankin disability score to assess functional outcome. The cases were evaluated with intracranial and extracranial vascular imaging studies, echocardiogram, and at least two determinations of prothrombotic states. RESULTS: In our hospital 11% of the patients with cerebral infarction under 45 years of age were labelled as cryptogenic. The mean age of the cases was 39.5 ± 5, 48 (49%) were women, 6 (6%) had arterial hypertension, 7 (7%) prior history of migraine, 32 (33%) were active smokers, 11 (11%) had hypercholesterolemia, and 11 (11%) had alcoholism. All cases were treated with aspirin. We observed good functional outcome (Rankin 0-2) in 65 (65%) cases. The anterior circulation was the most affected (partial in 56%, total in 12%). Infarction was unique in 87 (88%) cases. Recurrence was observed in 4 (4%) cases. CONCLUSIONS: In this study cryptogenic cerebral infarctions were mostly single, had low recurrence and good functional outcome in the long-term follow-up. Total anterior circulation infarctions correlated with poor outcome.

Clinical utility of two-dimensional doppler echocardiographic techniques for estimating pulmonary to systemic blood flow ratios in children with left to right shunting atrial septal defect, ventricular septal defect or patent ductus arteriosus.

Range gated two-dimensional Doppler echocardiographic methods were evaluated for quantifying pulmonary (QP) to systemic (QS) blood flow ratios. Twenty-one patients were studied, 4 with patent ductus arteriosus, 6 with atrial septal defect and 11 with ventricular septal defect. The Doppler pulmonary to systemic flow (QP:QS) estimation method involved calculating volume flow (liters/min) at a variety of intracardiac sites by using imaging information for flow area and Doppler outputs to calculate mean flow velocity as a function of time. Area volume flows were combined to yield QP:QS ratios. The sites sampled were main pulmonary artery, ascending aorta, mitral valve orifice and subpulmonary right ventricular outflow tract. The overall correlation between Doppler QP:QS estimates and those obtained at cardiac catheterization (n = 18) or radionuclide angiography (n = 3) was r = 0.85 (standard error of the estimate = 0.48:1). These preliminary results suggest that clinical application of this Doppler echocardiographic method should allow noninvasive estimation of the magnitude of cardiac shunts.

Normal intracardiac and great vessel Doppler flow velocities in infants and children.

Normal two-dimensional pulsed Doppler echocardiographic velocity profiles for sites within the heart and great vessels in a group of 102 normal infants and children are presented. Qualitatively, waveforms mimic expected hemodynamic events at the various sites. All waveforms had a rapid initial deflection followed by spectral broadening after attainment of peak velocity. Quantitative angle-corrected peak velocities were generally lower on the right side than on the left side of the heart. Differences in tricuspid (mean 61.8 cm/s) versus mitral (mean 81.1 cm/s) outflow and pulmonary (mean 76.1 cm/s) versus aortic (mean 88.5 cm/s) outflow were significant (p less than 0.01). The only significant age-related differences were in the pulmonary artery (mean for newborns 67.7 cm/s versus 79.6 cm/s for older children, p less than 0.01). Aortic data obtained from interrogation sites in which flow was close to 0 or 180 degrees were similar, whereas aortic peak velocity data obtained from apical long-axis or subcostal views were greater. These differences were probably induced from inaccuracies in azimuthal (elevational) angles that cannot be measured. These normal Doppler data should be useful for comparisons with data obtained for children with various forms of congenital heart disease that affect flow dynamics.

Total anomalous pulmonary venous connection in adults. Long-term follow-up.

Between 1961 and 1989, 19 patients with total anomalous pulmonary venous connection underwent surgical correction. Ages ranged from 18 to 38 years (mean 26.2 +/- 6.5 years). The anatomic variants included 10 patients with total anomalous pulmonary venous connection to the vertical vein, 6 patients with total anomalous pulmonary venous connection to the coronary sinus, and 2 with total anomalous pulmonary venous connection directly to the right atrium. The last patient had mixed connection to the coronary sinus and left vertical vein. Two patients died, one because of left atrial rupture and another of low cardiac output. Long-term follow-up after surgical repair ranged from 2 to 24 years (mean 7 +/- 6.2 standard deviation). Preoperative disability, assessed according to New York Heart Association criteria, showed 12 patients in functional class II and seven in class III. After treatment, 16 patients were in class I and one in class II (p less than 0.001). Echocardiographic evaluation of six patients revealed in all a normal left ventricular ejection fraction; the diastolic function was also normal except in one patient. The postoperative evaluation of the pulmonary arterial systolic pressure performed by both Doppler echocardiography and right cardiac catheterization in 14 patients showed a significant reduction of the mean pulmonary arterial systolic pressure from 51.1 +/- 3.4 to 37.4 +/- 14.4 mm Hg (p less than 0.01). The remaining three patients evaluated in the follow-up period only by clinical examination are in New York Heart Association functional class I. The anatomic characteristics of our patients were responsible for the long-term outcome without correction. Surgical treatment of older patients can be performed with satisfactory results and excellent long-term survival.

Intracardiac extension of malignant uterine tumors. Echocardiographic detection and successful surgical resection.

The echocardiographic findings of two unusual cases of malignant uterine tumors that invaded the heart are reported. A woman previously operated on for invasive cervical carcinoma had multiple embolic phenomena and evidence of obstruction to mitral flow. An echocardiogram showed a mass in the left atrium that reached the mitral valve ring. The tumor was implanted in a pulmonary vein and was removed with no complications. Cell type indicated metastatic carcinoma of the cervix. In the second case the patient had a large abdominal mass and precordial manifestations of obstruction and regurgitation of the tricuspid valve. An echocardiogram showed that a mass emanating from the inferior vena cava filled the right atrium and part of the right ventricle. The trajectory of the tumor was followed to its origin in an ovarian vein by tomography. The entire tumor was removed and identified as endometrial stromal sarcoma. An increase in operations with or without radiation therapy for malignant tumors has augmented the frequency of metastatic invasion of the heart; intracavitary extension tends to results from embolization or propagation along great veins. This is the first report of a uterine carcinoma reaching the heart by way of the pulmonary veins and of invasion of the heart by endometrial stromal sarcoma, both with successful excision.

Echocardiographic, catheterization, and nuclear medicine findings of an aneurysm of the muscular interventricular septum associated with aneurysm of the interatrial septum.

The unusual case of a young woman with an aneurysm of the muscular interventricular septum associated with an aneurysm of the interatrial septum and a muscular interventricular septal defect is presented. The echocardiographic, electrocardiographic, catheterization, and nuclear medicine findings are described.

Tetralogy of Fallot with absent pulmonary valve and total anomalous pulmonary venous connection.

It has been shown that congenital absence of the pulmonary valve rarely occurs by itself but tends to be associated with other heart defects, especially tetralogy of Fallot. Other malformations and other complex cardiac malformations also have been described in patients with absent pulmonary valve. In this report we describe the findings of a patient with this combination of cardiac defects who survived spontaneously to adulthood.

Transesophageal echocardiographic diagnosis of an aneurysm and thrombosis of the left anterior descending coronary artery.

An aneurysm of the left anterior descending coronary artery with thrombosis in its lumen in a 36-year-old woman who had an acute myocardial infarction is described. Although the aneurysm was detected by angiography, a transesophageal study provided new specific details of the exact site of origin of the aneurysm, as well as vascular thrombosis.

Transesophageal echocardiography and right atrial infarction.

Transesophageal echocardiographic findings in right atrial infarction are described. In three patients with myocardial infarction of one or both ventricles, the association of right atrial myocardial infarction was suspected because of anatomic (two-dimensional) and hemodynamic (Doppler) alterations obtained from transesophageal images. Transesophageal interrogation may prove widely applicable in the evaluation of patients with suspected right atrial infarction.

Anatomic correlation of left atrial appendage by 3-dimensional echocardiography.

The adequate study of the left atrial appendage is an echocardiographic challenge. The purpose of this study was to assess the ability of 3-dimensional echocardiography in reconstructing this potentially complex structure.

Two- and three-dimensional echocardiographic unroofed coronary sinus.

We present the 2-dimensional findings and 3-dimensional reconstruction of images from an 18-year-old patient with unroofed coronary sinus, persistent left superior vena cava, a common atrium with levoisomerism, ventricular septal defect, and double-outlet right ventricle. The left superior vena cava showed continuity with the floor of the coronary sinus. Diagnosis of the constellation of anomalies established by transesophageal reconstruction clarified the continuity of the coronary sinus with left superior vena cava and atrial wall.

Cor triatriatum dexter: transesophageal echocardiographic diagnosis and 3-dimensional reconstruction.

Cor triatriatum dexter is an unusual cardiac abnormality with division between the sinus and primitive atrial portions of the right atrium. Three-dimensional echocardiography is a novel technique that defines this entity.

Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction.

The echocardiographic findings of an intramyocardial dissecting hematoma that formed after an extensive acute myocardial infarction of the anterior wall of a 42-year- old man are described. Serial transesophageal studies were used to construct 3-dimensional images that clarified the participation of various myocardial layers that surrounded the dissecting hematoma. The patient was successfully treated with intra-aortic balloon counterpulsation and subsequently coronary artery bypass grafting. Intramyocardial dissecting hematoma is a rare complication of acute infarction; differential diagnosis must be made with pseudoaneurysm by establishing integrity of epicardium and with intracavitary thrombosis by identifying the endomyocardial layer surrounding the neoformation and associated wall movement.

The assessment of juxtaposed atrial appendages by transoesophageal echocardiography.

As part of a prospective study into the diagnostic role of transoesophageal echocardiography in children with complex congenital heart disease, the atrial morphology was assessed in 62 children. Using the direct visualization of atrial appendage morphology, 58 were shown to have usual atrial arrangement, two were documented to have isomerism of the right and two isomerism of the left appendages. Of those with usual arrangement, four children were demonstrated to have left juxtaposition of the atrial appendages. Only two of these patients were identified during praecordial echocardiographic re-evaluation, and three on angiocardiographic examination. Surgical confirmation was obtained in three, and juxtaposition was excluded in the remaining cases. The transoesophageal cross-sectional imaging features of left juxtaposition of the atrial appendages are unique and readily diagnostic of this entity. They include, first, a lateral deviation of the acid-portion of the atrial septum and, second, a frontal orientation of the antero-superior portion forming the floor and the posterior wall of the junction of the right-sided atrial appendage with the venous component of the atrial cavity. The knowledge of these morphologic characteristics is important, as, otherwise, this malformation may be misinterpreted as representing an atrial septal defect. The results suggest that transoesophageal echocardiography will be the most sensitive preoperative diagnostic technique in detecting or excluding juxtaposed atrial appendages.

[Echocardiography advances in infarction of the right ventricle]. / Avances ecocardiográficos en el infarto del ventrículo derecho.

This review describes echocardiographic findings in patients with inferior myocardial infarction and right ventricular extension. Transthoracic echocardiography has limitations to explore some wall segments of the right ventricle, especially the apical ones, as well as in the evaluation of the right atrial wall motion; further more, this technique offers poor information because this kind of patient frequently has a deficient thoracic acoustic window. Transesophageal echocardiography is the best non-invasive technique because it allows to evaluate all the right chamber segments; when complemented with the administration of dobutamine, it helps to identify viable myocardial tissue.

[Transesophageal echocardiographic findings in patients under 40 years of age with cerebrovascular event]. / Hallazgos ecocardiográficos transesofágicos en pacientes menores de 40 años con evento vascular cerebral.

UNLABELLED: The potential cardioembolic sources for ischemic stroke in patients younger than 40 years could be asymptomatic. The purpose of this study is to justify routine implementation of transesophageal echocardiography (TEE) in the study of young patients with ischemic stroke. MATERIAL AND METHODS: 34 patients younger than 40 years with ischemic stroke were studied with TEE complemented with contrast study, looking for potential cardioembolic sources or intracardiac shunts. RESULTS: 19 patients were male and 15 female with ages between 18-40 years (average 31 years). None had cardiac signs or symptoms. Eleven anomalies were detected in 20 patients (58.8%); of these, only 3 were considered as probably coursing with cardioembolic sources: patent foramen ovale (PFO), mitral valve prolapse, and ventricular enlargement, which were found in 12 patients (35.29%). In patients with cardiovascular anomalies, we found a hypercoagulable state, associated in eight patients with PFO (four patients), two with valvular thickening, and two with valvular nodules. CONCLUSIONS: In patients younger than 40 years with ischemic stroke, TEE is useful in detecting direct and indirect cardiac sources of embolism, even in those patients with unsuspected cardiac disease.

[Three-dimensional echocardiography: technique, clinical applications, and perspectives]. / Ecocardiografía tridimensional: técnica, aplicaciones clínicas y perspectivas.

OBJECTIVE: Three-dimensional echocardiography represents a new era in the contemporary cardiology, because depicts the cardiac structures in their realistic forms. This information can not be obtained using a two-dimensional perspective. Although two-dimensional (2D) and M-mode echocardiography has greatly enhanced the ability to visualize the functioning heart for more than 30 years, 3D interpretative mental skills are necessary to compile the 2D slices of the complex 3D anatomy, particularly in congenital heart disease. CONCLUSIONS: At present, its additional morphological and functional information in surgical decision-making and the increasing number of clinical questions than can be answered justify the clinical use of this technique. In the future it will the study of "virtual" pathologic anatomy.

[Transthoracic and transesophageal echocardiographic study in aortic valve replacement with pulmonary valve autograft]. / El estudio con ecocardiografía transtorácica y transesofágica del reemplazo valvular aórtico con autoinjerto valvular pulmonar.

Eleven patients who underwent pulmonary valve autograft to aortic position with placement of bovine pericardial prosthesis in pulmonary position were studied with echocardiography. Transthoracic echocardiography, was performed on all patients before surgery. Transesophageal echocardiograms were practiced during the surgical procedure. The latter technique aided in immediate postoperative evaluation. Transthoracic and transesophageal echocardiography provide a practical and valuable means of investigating the pre, trans and postoperative conditions of patients undergoing Ross surgery.