Three-year follow-up of the Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease (ERACI).

OBJECTIVES: The purpose of this study was to report the 3-year follow-up results of the ERACI trial (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease). BACKGROUND: Although coronary angioplasty has been used with increased frequency in patients with multivessel coronary artery disease, its value, compared with bypass graft surgery, has not been established. Thus, controlled, randomized clinical trials such as the ERACI are needed. METHODS: In this trial 127 patients who had multivessel coronary artery disease and clinical indication of myocardial revascularization were randomized to undergo coronary angioplasty (n = 63) or bypass surgery (n = 64). The primary end point of this study was event-free survival (survival with freedom from myocardial infarction, angina and new revascularization procedures) for both groups of patients at 1, 3 and 5 years of follow-up. RESULTS: Freedom from combined cardiac events (death, Q-wave myocardial infarction, angina and repeat revascularization procedures) was significantly greater for the bypass surgery group than the coronary angioplasty group (77% vs. 47%; p < 0.001). There were no differences in overall (4.7% vs. 9.5%; p = 0.5) and cardiac (4.7% vs. 4.7%; p = 1) mortality or in the frequency of myocardial infarction (7.8% vs. 7.8%; p = 0.8) between the two groups. However, patients who had bypass surgery were more frequently free of angina (79% vs. 57%; p < 0.001) and required fewer additional reinterventions (6.3% vs. 37%; p < 0.001) than patients who had coronary angioplasty. CONCLUSIONS: 1) Freedom from combined cardiac events at 3-year follow-up was greater in patients who had bypass surgery than in those who had coronary angioplasty. 2) The coronary angioplasty group had a higher incidence of recurrence of angina and the need for repeat revascularization procedures. 3) Cumulative cost at 3-year follow-up was greater for the bypass surgery group than for the coronary angioplasty group.

[Thrombolytic therapy in a case of prosthetic aortic valve thrombosis]. / Trombolíticos en el tratamiento de un caso de trombosis valvular protésica en posición aórtica.

We present the case of a 40 year old woman, who had an aortic prosthetic valve, of the Björk Shiley type. Three months before admission she began with progressive dyspnea. She was admitted to the Cardiovascular Care Unit with a global cardiac failure. An aortic prosthetic valve thrombosis was diagnosed clinically (absence of the prosthetic click) and by radioscopy (a decrease in the movement of the valve disk, with an incomplete shunt). It was attributed to a secondary failure of the anticoagulant treatment. Despite the treatment she quickly developed a cardiogenic shock. A treatment with 750,000 UI of streptokinase in 30 min was started, followed by 100,000 UI during 12 hours, with total reversion of the hemodynamic features, as judged by clinical examination (recurrence of the prosthetic click), radioscopy (recurrence of the valve movement) and by Doppler echocardiography (reduction of the transvalvular gradient). No complications were observed, and in a follow up of 12 months she persisted asymptomatic. The prosthetic valve thrombosis is an infrequent and almost fatal complication. The classical therapy consists in surgery which is a procedure with a high mortality in patients with severe cardiac failure, and an emergency procedure, as it occurred in our patient. Despite the known success of the thrombolytic therapy in the prosthetic valve thrombosis of the right heart (tricuspid position) it was only in the last years that this treatment was reported in aortic or mitral position. Peripheric embolies were found in 13% of the cases, always with transitory symptoms. There are only 45 cases described in the world, and more experience is needed for definitive conclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Verapamil effects on retrograde dual A-V conduction.

Un hombre de 34 anos con crisis de taquicardias paroxisticas recurrentes y sin cardiopatia demostrable presentaba en sus ECGs de superficie la variedad lenta-rapida de re-entrada intranodal (Fig. 1 A). El estudio electrofisiologico efectuado durante el ritmo sinusal mostro tiempos de conduccion normales (Fig. 1, B). Mediante estimulacion auricular y ventricular crecientes se observo conduccion A-V dual anterograda (Fig. 2, A) y retrograda (Fig.2, B) repectivamente. El verapamil (10 mg, endovenoso "en bolo") produjo un bloqueo de la via lenta anterograda (Fig. 3, A) y de las dos vias de conduccion retrograda (Fig. 3, B). Administrada luego por via bucal (80 mg cada 6 h) dicha droga resulto eficaz para prevenir los paroxismos taquicardicos durante 18 meses de seguimiento. De nuestro conocimiento, el bloqueo simultaneo de ambas vias de conduccion A-V retrograda no ha sido relatado hasta la fecha

Tromboliticos en el tratamiento de un caso de trombosis valvular protesica en posicion aortica / Thrombolytic therapy in a case of prosthetic aortic valve thrombosis

Se presenta el caso de una paciente de sexo femenino, de 40 años de edad, portadora de una prótesis valvular tipo Björk Shiley en posición aórtica quien sufrió como complicación la trombosis de la misma, con progesivo deterioro hemodinámico, hasta llegar al schock cardidogénico. Se administró tratamiento trombolítico, con reversión total del cuadro. La conducta terapéutica tradicional es la quirúrgica, con elevado índice de mortalidad perioperatoria. Si bien el tratamiento trombolítico en trombosis de prótesis valvulares en posición tricuspídea fue sugerido desde 1971, hay pocos casos relatados de su aplicación a nivel de prótesis de cavidades izquierdas. Precisamente el motivo de este trabajo es la presentación de un caso, con la revisión de la literatura y el análisis de los beneficios potenciales de esta terapéutica

Disociacion auricular. Paro auricular unilateral. / Auricular dissociation.Unilateral auricular standstill

Se relata el caso de una paciente con bloqueo A-V completo con complejos QRS anchos y ondas "f" de muy escaso voltaje, solo evidenciables en tiras de ritmo de larga duracion. Sobre la base de las caracteristicas de estas ultimas se postulo la existencia de una fibrilacion limitada a un sector de las auriculas, con falta de actividad electrica del resto del miocardio auricular. El estudio electrofisiologico demostro un fibriloaleteo de los dos tercios inferiores de la auricula derecha y paro electrico en el tercio superior de esta ultima, asi como en toda la auricula izquierda. Al igual que ha sucedido con otras afecciones, las derivaciones intracavitarias obtenidas en este paciente, han permitido revalidar hallazgos de la electrocardiografia clinica

Sindrome de las fibras de Mahaim. / Mahain's fibers syndrome

Se relata el caso de un paciente que presenta por primera vez crisis taquicardicas de muy alta frecuencia ventricular (mayores de 250 por minuto) a la edad de 69 anos. No tenia antecedentes cardiovasculares y no presentaba signos de cardiopatia organica. En base al examen electrovectocardiografico se presumio un sindrome de las fibras de Mahain (P-R: 0.15 seg, QRS: 0.12 seg, nitida onda delta) que fue confirmado por el estudio electrofisiologico (intervalo A-H normal, H-V disminuido,prolongacion del primero y del intervalo A-V sin cambios sustanciales del intervalo H-V) en diastoles cortas secundarias a extrasistoles auriculares espontaneos y marcapaseo auricular. Se indico propranolol (80 mg/dia, por boca) y controle periodicos (incluyendo ECG Holter de 24 h) durante um largo seguimiento (5 anos).Todo ello demostro la ausencia de taquiarritmias y el paciente permanecio asintomatico hasta la actualidad. El mayor interes de este caso con una rara forma de pre-excitacion radica en el comienzo tardio de arritmias que pusieron en peligro su vida y en el control prolongado de la eficacia del propranolol para prevenir las recidivas