Pseudoaneurisma de la fibrosa mitro aórtica en endocarditis de aorta bicúspide: A propósito de un caso / Pseudo-aneurism of the mitral aortic intervalvular fibrosa in a patient with bicuspid aortic valve endocarditis: A case report

El pseudoaneurisma de la fibrosa mitro aórtica es una complicación infrecuente pero potencialmente fatal de la endocarditis infecciosa de válvula aórtica. El diagnóstico de pseudoaneurisma se realiza mediante una técnica de imagen, principalmente la ecocardiografía transtorácica y transesofágica, en la que se evidencia una cavidad perivalvular pulsátil con expansión sistólica y colapso diastólico localizada en la zona mitro-aórtica. Por el riesgo de complicaciones, en la mayoría de pacientes, se recomienda el reemplazo de válvula aórtica con cierre del pseudoaneurisma. Se presenta un caso de pseudoaneurisma de la fibrosa mitro aórtica en un paciente adulto joven con endocarditis de válvula aórtica bicúspide. (AU)

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is an infrequent but potentially fatal complication of aortic valve endocarditis. Diagnostic is done by an imaging technique, especially transthoracic and transesophageal echocardiography, consisting of a pulsatile cavity with systolic expansion and diastolic collapse located in the mitral-aortic intervalvular fibrosa. Due to the risk of complications, aortic valve replacement and closure of the pseudoaneurysm is recommended. We present a case of pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient presenting with bicuspid aortic valve endocarditis. (AU)

Factores asociados a la anticoagulación oral óptima en el adulto mayor con fibrilación auricular / Factors associated with optimal oral anticoagulation in elder patients with atrial fibrillation

Objetivos: Determinar la calidad del control de la anticoagulación oral y los posibles factores asociados al tiempo de rango terapéutico. Material y métodos: Estudio retrospectivo con grupo control y exploración de posibles variables, realizado en pacientes =65 años con fibrilación no valvular e indicación de anticoagulación del Hospital Cayetano Heredia entre el 2011-2013. Se determinó el tiempo de rango terapéutico (TRT) por el método de Rosendaal y se consideró control óptimo (TRT =60%) y subóptimo (TRT <60%). Se realizó análisis univariado para los factores. Resultados: La mediana de la edad fue 82,23 años, 74 (51,75%) fueron mujeres. Ciento cuarenta pacientes tuvieron indicación de anticoagulación, 94 (67,14%) iniciaron warfarina, 28 (19,72%) tuvo control óptimo y 66 (46,48%) subóptimo. La edad =75 años (OR 25,5; IC: 7,39-155,8), no bajo grado de instrucción (OR 8; IC 3,61-20,61), =3 comorbilidades (OR 4,5; IC 2,33-9,39), discontinuidad terapéutica (OR 2,75; IC 1,44-5,52) y polifarmacia (OR 4,2; IC 2,16-8,80) se asociaron con control subóptimo, mientras que independencia funcional (OR 4,3; IC 2,16-9,47), no deterioro cognitivo (OR 7,8; IC 3,53-20,19) y género femenino (OR 3; IC 1,62-5,81) al control óptimo. Conclusiones: Un gran porcentaje de pacientes con indicación de ACO y con bajo riesgo de sangrado no inició terapia anticoagulante; y el 50% de quienes la iniciaron, tuvo un control subóptimo. Los pacientes de mayor edad, con mayor comorbilidad y el uso de múltiples medicamentos se asociaron con control subóptimo; mientras que el género femenino y la independencia funcional se asociaron con control óptimo. (AU)

Objective: To determine the quality of oral anticoagulation control and the possible factors associated with time to reach therapeutic range. Methods: Retrospective study with a control group in patients =65 years old with nonvalvular atrial fibrillation who had indication for oral anticoagulation at Hospital Cayetano Heredia from 2011 to 2013. Time to therapeutic range (TTR) was determined by the Rosendal´s method, an optimal control was defined as TTR =60%. A multivariate analysis was performed. Results: Median age was 82.23 years; 74 (51.75%) were females; 140 patients had indication for anticoagulation; 94 (67.14%) started warfarin; 28 (19.72%) had optimal control and 66 did not (46.48%). Age = 75 years (OR 25.5; CI: 7.39-155.8) and no low degree of instruction (OR 25.5; CI: 7.39-155.8) were associated with sub optimal control, while functional independence (OR 4.3; CI: 2.16-9.47), no cognitive deterioration (OR 7.8; CI: 3.53-20.19) and female gender (OR 3; CI: 1.62-5.81) were associated with optimal control. Conclusions: A great percentage of patients with indications for oral anticoagulation and at low risk of bleeding did not start it, and 50% of those who started it had suboptimal control. Older patients with comorbidities who used multiple medications had sub optimal control, while females and functional independence were associated with optimal control. (AU)

Insidious onset of intermittent claudication as the primary manifestation of infective endocarditis.

Musculoskeletal manifestations of infective endocarditis are well-described in the literature. However, insidious onset of localized calf pain is an uncommon presentation of embolization and may represent a diagnostic challenge owing to the nonspecific nature of the symptoms. This study reviewed the literature and reports a case of infective endocarditis in a patient who presented with bilateral calf pain as the primary complaint and reason for seeking medical attention.

Kissing abscess de la valva anterior mitral y pseudoaneurisma por endocarditis infecciosa de la válvula aórtica / Kissing-abscess of the anterior mitral valve and pseudo aneurism due to infective endocarditis of the aortic valve

Un mecanismo inusual de complicación de endocarditis infecciosa (EI) aórtica es llamado ôkissing abscessõ, producido por el impacto del flujo de la regurgitación aórtica y contacto de las vegetaciones sobre la valva anterior mitral. Los abscesos de la válvula mitral pueden complicarse con pseudoaneurismas. Se presenta el caso de un varón de 36 años con fiebre y sudoración de tres meses de evolución. Además, soplo diastólico aórtico y hepatomegalia. La ecocardiografía transesofágica (ETE) mostró válvula aórtica bicúspide con insuficiencia severa y perforación del seno no coronariano con múltiples vegetaciones de tamaño promedio de 4 mm, válvula mitral anterior con imagen anecogénica de 14 mm que corresponde a absceso con flujo Doppler en su interior y otra imagen anecogénica de pseudoaneurisma y múltiples vegetaciones subvalvulares. La extensión de la infección de la EI aórtica a la válvula mitral es una complicación con alta tasa de mortalidad, por ello es necesario el diagnóstico temprano.

An unusual complication of infective endocarditis (IE) of the aortic valve is called kissing-abscess, caused by the impact of the flow of aortic regurgitation and subsequent contact of vegetations over the anterior mitral valve. The resulting abscesses on the mitral valve can further complicate forming pseud aneurisms. We present the case of a 36-year-old male patient with a 3-month history of fever. A diastolic murmur on the aortic chest wall area was listened and hepatomegaly was also found on the physical examination. A trans-esophageal echocardiography revealed severe aortic insufficiency and perforation of the non-coronary sinus with multiple vegetations, mean size of 4 mm. In addition, the anterior mitral valve had a hypo-echogenic image of 14mm in size consistent with an abscess with Doppler flow in its interior and a pseudo aneurism with multiple sub-valvular vegetations. The extension of IE from the aortic to the mitral valve is associated with high mortality rate needing a prompt diagnosis.

El Cuadro de Mando Integral en la ejecución del plan estratégico de un hospital general / The Balanced Scorecard in strategic plan implementation of a general hospital

Este estudio se centra en el proceso de aplicación del Cuadro de Mando Integral (CMI), como instrumento de gestión que alinea y comunica los objetivos estratégicos de la organización. Objetivo: Evaluar la utilidad del Cuadro de Mando Integral en la ejecución del Plan Estratégico de un hospital general. Material y métodos: Estudio descriptivo, observacional y retrospectivo realizado en el Hospital Nacional Cayetano Heredia (HNCH) desde enero 2008 a junio de 2009. Resultados: Reducción de los rechazos por prestaciones valorizadas al Seguro Integral de Salud de 13,64% a 8,93%, disminución de las operaciones suspendidas de 13,04% a 9,83%, optimización de la utilización de camas de 79,23% a 91,15%, el desempeño de los planes operativos de las unidades orgánicas que alcanzaron nivel óptimo fue de 33,33% y las unidades orgánicas que expusieron las mejores presentaciones se incrementó de 8% a 40%. Conclusiones: La aplicación del CMI fue útil como instrumento de seguimiento y control de la ejecución del Plan Estratégico Institucional.

This research focuses on the process of implementing the Balanced Scorecard (BSC) as a management tool that aligns and communicates the strategic objectives of the organization. Objective: To evaluate effect of BSC in the Strategic Plan in a highly specialized general hospital. Material and methods: Descriptive, observational and retrospective research developed at the Hospital Nacional Cayetano Heredia. Results: A reduction of benefits refusals by the Comprehensive Health Insurance from 13.64% to 8.93%, a reduction of suspended surgical procedures from 13.04% to 9.83%, and an increase in the optimal use beds from 79.23% to 91.15% were observed. The performance of operational plans of the areas that achieved optimal level was 33.33% and the organic units that gave the best presentations increased from 8% to 40%. Conclusions: The implementation of BSC was useful in a general hospital as a tool for monitoring and control of the execution of the Institutional Strategic Plan.

Total anomalous pulmonary venous return and Mayer-Rokitansky-Kuster-Hauser syndrome.

We present an adult woman with total anomalous pulmonary venous return (TAPVR) and Mayer-Rokitansky-Kuster-Hauser syndrome that was diagnosed intraoperatively during a planned atrial secundum defect closure. Surgical repair of TAPVR was performed with good outcome.

A large pediculated myxoma of the left ventricle causing outflow obstruction in a young man.

We report a case of a large mobile myxoma of the left ventricle that caused obstruction of the outflow tract. Transthoracic and transesophageal echocardiography defined the extent and location of the mass providing crucial information for surgical treatment, which was successful.

Right ventricular function and ventricular perfusion defects in adults with congenitally corrected transposition: correlation of echocardiography and nuclear medicine.

We undertook our study in order to evaluate right ventricular function and perfusion by conventional and contrast echocardiography in adults with congenitally corrected transposition who had not undergone cardiac surgery, comparing the echocardiographic findings with those obtained using equilibrium radionuclide ventriculography and gated single-photon emission computed tomography with Technetiumc-99 m sestamibi. We discovered severe tricuspid regurgitation in 8 patients (61%). Right ventricular ejection fraction, as calculated by nuclear medicine, had a correlation of 0.67 (p = 0.059) with area fractional shortening and 0.84 (p = 0.01) with ejection fraction calculated by the method depending on descent of the tricuspid ring. All patients with severe tricuspid regurgitation also had right ventricular dysfunction. Of these 8 patients, 7 had persistent perfusion defects, while 6 also had ischemic perfusion defects. Echo contrast had a high sensitivity, at 91%, and also specificity and positive predictive value, both at 100%, for persistent defects, and a negative predictive value of 66% compared to methods depending on nuclear medicine. The sensitivity of contrast echocardiography for detection of ischemic defects was 66%, the specificity 100%, the positive predictive value 100%, and the negative predictive value 77% compared to the methods involving nuclear medicine. The method depending on descent of the tricuspid ring had the highest correlation with equilibrium radionuclide ventriculography in evaluation of right ventricular function in patients with congenitally corrected transposition. We conclude that contrast echocardiography is extremely valuable when assessing right ventricular myocardial perfusion, having high sensitivity and specificity for detecting persistent defects, although sensitivity was less for detection of ischemic defects than that of gated single-photon emission computed tomography with Technetium-99 m Sestamibi. Persistent and ischemic perfusion defects, together with chronic volume overload from tricuspid regurgitation, are the determining factors of right ventricular dysfunction.