Extractos de los documentos de posicionamientos y recomendaciones mexicanas en enfermedades cardiovasculares y COVID-19 / Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19

Resumen Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Abstract The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

[Transcatheter aortic valve implantation for aortic stenosis. Initial experience]. / Tratamiento de la estenosis valvular aórtica con implante de prótesis valvular transcatéter. Experiencia inicial.

BACKGROUND: Aortic stenosis is a frequent disease in the elderly, and is associated with other systemic pathologies that may contraindicate the surgical procedure. Another option for these patients is percutaneous aortic valve implantation, which is less invasive. We present our initial experience with this procedure. MATERIAL AND METHODS: Patients with aortic stenosis were included once selection criteria were accomplished. Under general anaesthesia and echocardiographic and fluosocopic control, a transcatheter aortic valve was implanted following s valvuloplasty. Once concluded the procedure, angiographic and pressure control was realized in order to confirm the valve function. RESULTS: Between November 2014 and May 2015, 6 patients were treated (4 males and 2 females), with a mean age of 78.83±5.66 years-old. The preoperative transvalvular gradient was 90.16±28.53mmHg and posterior to valve implant was 3.33±2.92mmHg (P<.05). Two patients had concomitant coronary artery disease which had been treated previously. One patient presented with acute right coronary artery occlusion which was immediately treated. However due to previous renal failure, postoperative sepsis and respiratory failure, the patient died one month later. CONCLUSION: It was concluded that our preliminary results showed that in selected patients percutaneous aortic valve implantation is a safe procedure with clinical improvement for treated patients.

[Combined heart-kidney transplantation in Mexic]. / Trasplante combinado de corazón-riñón en México.

BACKGROUND: In our country, heart and kidney transplantation is a novel option for treatment of combined terminal heart and kidney failure. This program began in 2012 for selected patients with documented terminal heart failure and structural kidney damage with renal failure. Description of cases: Between January 1, 2012 and April 30, 2016, we made 92 orthotopic heart transplantations. In five of these cases the heart transplantation was combined with kidney transplantation. RESULTS: There were three male and two female patients with a mean age 25.6 ± 5.2 years (range, 17-29). The patients improved their renal function and the heart transplantation was successful with an improved quality of life. One patient died from abdominal sepsis. The other patients are doing well. CONCLUSION: The combined heart-kidney transplantation is a safe and efficient procedure for patients with structural kidney and heart damage as a cause of terminal failure.

[Primary cardiac hemangioendothelioma: early diagnosis and surgical resection]. / Hemangioendotelioma cardiaco primario: diagnóstico y resección quirúrgica temprana.

BACKGROUND: The term hemangioendothelioma encompasses all tumors that derive from the endothelium of blood vessels. It has an uncertain prognosis, and it is always considered as a low-grade malignancy. CLINICAL CASE: Male, 23, who was admitted to the emergency room with chest pain, intermittent paroxysmal nocturnal dyspnea and malaise. He denied having a history of degenerative diseases, and had a weight loss of 6 kg in two months. Chest X-rays suggested pericardial effusion. Patient presented a tendency to hypotension tamponade, which was solved with subxiphoid puncture, and drain 800 mL of liquid from ancient hematological parameters. He presented a tumor in the right atrium of 8x4 cm, attached to the anterior wall of the atrium without involucre of interatrial septum. When patient underwent surgery, it was identified a tumor lesion in the anterior wall of right appendage. It was done the resection of the tumor and of 70% of the right atrial appendage. The latter was replaced with bovine pericardium. Patient showed good outcome; it was discharged after 10 days of follow-up surgery for six months in the outpatient clinic. CONCLUSION: The hemangioendothelioma is a vascular tumor of unpredictable behavior, and whose origin rarely comes from the heart. A timely detection, and a radical surgical resection is, so far, the more acceptable management, given the worldwide little experience for handling this type of tumor. Our experience suggests an aggressive clinical approach and surgical removal within the first hours of the suspected diagnosis for the greatest chance of complete resection and reducing the risk of recurrence.

Introducción: el hemangioendotelioma engloba todos los tumores que derivan del endotelio de los vasos sanguíneos. Es de pronóstico incierto y siempre se considera como una lesión maligna de bajo grado. Caso clínico: paciente masculino de 23 años que ingresó a urgencias con dolor retroesternal intermitente, disnea paroxística nocturna y ataque al estado general. Negó antecedentes crónico-degenerativos y tuvo pérdida ponderal de 6 kg en dos meses. Las pruebas sugirieron derrame pericárdico. Presentó tendencia a la hipotensión por tamponade, resuelta con punción subxifoidea, y drenaje de 800 mL de líquido de características hemáticas antiguas. El paciente presentó un tumor de la aurícula derecha de 8 x 4 cm, dependiente de la pared anterior de la aurícula, sin involucro de septum interatrial. Al someter al paciente a cirugía, se identificó lesión tumoral en la pared anterior de orejuela derecha. Se hizo resección del tumor y del 70 % de la orejuela derecha, sustituida con parche de pericardio bovino. El paciente presentó buena evolución; egresó a los 10 días de la cirugía con seguimiento por seis meses en la consulta externa. Conclusión: estamos ante un tumor vascular oncológicamente impredecible y que rara vez se origina en el corazón. Una detección oportuna y la resección quirúrgica radical es el manejo más aceptado ante la poca experiencia que hay a nivel mundial para lidiar con esta entidad. Sugerimos un abordaje clínico agresivo y la extirpación quirúrgica dentro de las primeras horas de la sospecha diagnóstica para obtener la mayor posibilidad de resección total y la reducción del riesgo de recidiva.

[Routine hormonal therapy in the heart transplant donor]. / Terapia hormonal de rutina en el donador para trasplante cardiaco.

BACKGROUND: Successful heart transplantation depends largely on donor heart function. During brain death many hormonal changes occur. These events lead to the deterioration of the donor hearts. The 2002 Crystal Consensus advises the use of a triple hormonal scheme to rescue marginal cardiac organs. MATERIAL AND METHODS: A prospective, longitudinal study was conducted on potential donor hearts during the period 1 July 2011 to 31 May 2013. All donor hearts received a dual hormonal rescue scheme, with methylprednisolone 15mg/kg IV and 200mcg levothyroxine by the enteral route. There was at least a 4 hour wait prior to the harvesting. The preload and afterload was optimised. The variables measured were: left ventricular ejection fraction cardiac graft recipient; immediate and delayed mortality. RESULTS: A total of 30 orthotopic heart transplants were performed, 11 female and 19 male patients, with age range between 19 and 63 years-old (Mean: 44.3, SD 12.92 years). The donor hearts were 7 female and 23 male, with age range between 15 and 45 years-old (mean 22.5, SD 7.3 years). Immediate mortality was 3.3%, 3.3% intermediate, and delayed 3.3%, with total 30 day-mortality of 10%. Month survival was 90%. The immediate graft left ventricular ejection fraction was 45%, 60% intermediate, and 68% delayed. The causes of death were: 1 primary graft dysfunction, one massive pulmonary embolism, and one due to nosocomial pneumonia. CONCLUSION: It was concluded that the use of double rescue scheme hormonal therapy is useful for the recovery and preservation of the donor hearts. This scheme improves survival within the first 30 days after transplantation.

[Mucha-Habermann disease and orthotopic heart transplant. Case report]. / Enfermedad de Mucha-Habermann y trasplante ortotópico de corazón. Informe de un caso clínico.

BACKGROUND: Mucha-Habermann disease is a cutaneous clinical manifestation of unknown etiology that frequently appears in young patients. The aim was to present Mucha-Habermann disease that occurred in an old man who had a heart transplant. CLINICAL CASE: a 62 year-old male, heart transplant recipient, who four years after that transplantation procedure presented with papular lesions in neck, thoracic members of which extended to all body surfaces and that evolved vesicles and pustular lesions. A skin biopsy was performed and Mucha-Habermann disease was diagnosed. The patient was treated with steroids and antimicrobial therapy with favorable response. After two years there are no skin lesions. CONCLUSIONS: Mucha-Habermann disease is a low frequency disease and it requires skin biopsy to confirm diagnose. This is an uncommon case due to the age and kind of patient.

Introducción: la enfermedad de Mucha-Habermann es la afección cutánea de etiología desconocida más frecuente en los pacientes jóvenes. Se caracteriza por la erupción aguda de lesiones papulares que evolucionan a vesículas, pústulas y cicatrices deprimidas hiperpigmentadas de aspecto varioliforme. Su curso habitual es subagudo o crónico. El objetivo es describir la enfermedad de Mucha-Habermann en un hombre con trasplante ortotópico de corazón. Caso clínico: hombre de 62 años de edad que cuatro años después de recibir trasplante de corazón presentó lesiones papulares diseminadas en cuello y miembros torácicos, las cuales se extendieron al resto del cuerpo y evolucionaron a vesículas y pústulas. Se obtuvo biopsia de piel y se conformó el diagnóstico de enfermedad de Mucha-Habermann. El paciente recibió tratamiento con esteroide y antimicrobiano, al que respondió favorablemente. Al momento de este informe, las lesiones habían desaparecido. Conclusiones: la enfermedad de Mucha-Habermann es poco frecuente y requiere confirmación mediante biopsia de piel para tratarla adecuadamente. El caso que se describe es poco común por el tipo de paciente y la edad en que se manifestó la enfermedad.

Pleomorphic malignant histiocytoma of pulmonary arteries presenting as pulmonary aneurysms.

Pulmonary aneurysms and primary neoplasms of the great vessels are very rare entities; pulmonary aneurysms are commonly associated with congenital heart diseases, and less frequently in atherosclerosis, medial cystic necrosis, trauma, infection, and inflammatory processes. Many patients have pulmonary hypertension, most frequently resulting from pulmonary artery sarcomas mimicking pulmonary thromboembolism. Symptoms are vague. In 30% of cases, rupture and death occur, related to pulmonary aneurysms. We present the case of a patient with a diagnosis of pulmonary artery pleomorphic malignant histiocytoma that presented as a right pulmonary aneurysm thrombosis and a contained rupture of a left pulmonary aneurysm.

Retiro de "Stents" intracoronarios y cirugía de revascularización miocárdica / Retirada de "Stents" intracoronários e irurgia de revascularização miocárdica / Intracoronay “stents” removal and coronary artery Bypass grafting surgery

Introducción: es cada vez más frecuente la necesidad de retirar “stents” en la cirugía de revascularización. Material y métodos: serie de casos en los que se realiza endarterectomía y retiro de “stents” de vasos coronarios entre el 1 de enero y el 30 de abril del 2011. Se analizó morbilidad, antecedentes y evolución. Resultados: tres pacientes requirieron remoción de “stents”, dos de la descendente anterior y uno de la coronaria derecha, un paciente con infarto del miocardio falleció por choque cardiogénico. Conclusión: La remoción de “stents” en cirugía de revascularización debe considerar se como opción terapéutica en casos bien determinados.

Introdução: Cada vez é mais frequente a necessidade de retirar “stents” na cirurgia de revascularização. Material e métodos: série de casos onde são realizadas endarterectomia e retirada de“stents” de artérias coronárias entre 1 de janeiro e 30 de abril de 2011. Analisou-se morbilidade, antecedentes e evolução. Resultados: três pacientes tiveram remoção de “stents”, dois da artéria descendente anterior e um da coronária direita, um paciente com infarto do miocárdio faleceu por choquecardiogênico. Conclusão: A remoção de “stents” em cirurgia de revascularização deve considerar-se como opção terapêutica em casos bem determinantes.

Introduction: Stent removal is associated to coronary artery by-pass surgery is a more fre-quent procedure. Material and Methods: We present the cases that required endarterectomy, stent removal and coronary artery by-pass surgery between January 1, 2011, and April 30, 2011. We analyzedmedical history, morbidity, and evolution.Results: Three patients required stents removal, two in coronary anterior descending artery and one on right coronary artery. One patient with acute myocardial infarction died, due tocardiogenic shock. Conclusion: It was concluded that stent removal in coronary artery by-pass surgery shouldbe considered as a surgical option in selected cases.

[Gated single photon emission computed tomography (SPECT) and radionuclide ventriculography for evaluate the left ventricle ejection fraction in heart transplant recipients. Comparative study]. / Comparación de la ventriculografía isotópica de equilibrio y la tomografía computarizada con emisión de fotones individuales (SPECT) sincronizado para evaluar la fracción de expulsión del ventrículo izquierdo en pacientes trasplantados de corazón.

OBJECTIVE: To evaluate which is the best method to determine the left ventricular ejection fraction in heart transplant recipients: radionuclide ventriculography or gated SPECT, compared with echocardiography as the gold standard method. MATERIAL AND METHODS: A prospective, transversal, observational, and open study including all orthotopic heart transplant recipients between January 1, 1993 and December 31, 2010 was realized after signed Informed Consent, and we performed echocardiography, radionuclide ventriculography and gated SPECT in 14 patients. Normal value for left ventricle ejection fraction was considered 50% in all the methods. RESULTS: Fourteen heart transplant recipients were considered for the study. Two patients were excluded because of arrhythmic heartbeat at the time of gated SPECT acquisition and two by being newly transplanted. The mean left ventricle ejection fraction was: echocardiography: 69.9%;gated SPECT: 60%; radionuclide ventriculography: 61.1%. The sensitivity of gated SPECT was 75% and 100% for radionuclide ventriculography. Specificity could not be obtained because our population was very small and there were no false negatives. (All the echocardiography results were over 50%). CONCLUSION: It was concluded that despite our small population, the gated SPECT was a useful tool in the evaluation of heart transplant patients due to its functional and prognostic information, besides offering myocardial perfusion imaging.

[Brain death, physiopathology, optimal care and hormonal therapy for cardiac donation]. / Muerte encefálica, fisiopatología, cuidado óptimo y terapia hormonal para donación cardíaca.

Heart transplantation goes on leading the standard therapy for the terminal heart failure. The success of this procedure and the post-transplantation survival, meaning during the perioperative time, is variable because of the good performance of the donor graft, due to this situation, the pre-harvesting evaluation is very important. The brain death brought many changes: 1) first of all the "adrenergic storm" with its hemodynamic and cardiac dangerous events; 2) Thyroidal hormones, cortisol, vasopressin, and seric insulin depletion with its metabolic consequences respectively. Since 2002 during the Crystal Consensus started the using of the hormonal therapeutic with triyodothironine, vasopressin and metilprednisolone for improving, meaning those limitrophes ones, the performance donor hearts with brain death, and the goal has been to harvest more donated organs en quality and numbers. This hormonal therapeutic has had great acceptation and is successful; having more harvesting of solids organs: hearts, lungs and kidneys; with more performance and surviving at 1 year post-transplantation and less mortality. Our Hospital began the hormonal therapeutic since January 2011with excellent results. On this basis we can concluded that, hormonal rescue therapy, improves the availability and performance of organs for transplantation.

[Heart transplant program at the UMAE, General Hospital Dr. Gaudencio González Garza, of the La Raza National Medical Center]. / Programa de trasplante cardiaco de la unidad Médica de Alta Especialidad, Hospital General Dr. Gaudencio González Garza, del Centro Médico Nacional la Raza.

BACKGROUND: The heart transplantation has modified the life expectancy of patients with terminal heart failure. OBJECTIVE: To present our experience in heart transplantation. MATERIAL AND METHODS: A retrospective cohort study was realized for heart transplant recipients between July 21, 1988 and May 30, 2011. We evaluated the procedure for evaluation and selection of heart donors and heart transplant recipients. Also we reviewed etiology of cardiomiopathy, age and gender of patients, surgical procedure, and postoperative evolution, immediate and long-term survival. RESULTS: Of all 233 heart transplants performed in Mexico, 64 were done in our hospital. Seven cases were excluded due to incomplete information. We present 57 heart transplantation performed in 56 patients (one retransplantation): 27 cases with dilated cardiomiopathy (47.35%), 23 with ischemic cardiomiopathy (40.35%), four patients with terminal heart valve disease (7.0%), two with restrictive cardiomiopathy (3.5%) and one retransplantation (1.8%). Forty-six male patients (82.1%), and 10 female cases (17.9%). The mean age was 40.9 +/- 15.6 years-old (8-66 years-old). In 22 years the immediate mortality was 30.3% and the main cause was primary graft failure. The longest survival has been 10 years. All survival recipients are in functional class I. CONCLUSION: It was concluded that heart transplantation is a feasible surgical option in our country for terminal heart disease.

Coronary artery bypass grafting surgery with minimal extracorporeal circulation system.

BACKGROUND: For coronary artery bypass graft (CABG) surgery, cardiopulmonary bypass (CPB) is required for many patients. However, this procedure has several risks. Our objective was to test the hypothesis that the minimal extracorporeal circulation circuit (MECC) is more advantageous than CPB for CABG surgery. METHODS: We analyzed 17 patients submitted to CABG surgery between April 1, 2006 and August 31, 2009. Patients were divided into two groups. In one group, MECC (n = 8) was used and in the other group the conventional CPB circuit (n = 9). Perioperative bleeding, blood requirements and clinical evolution were compared. RESULTS: We observed a statistically significant difference for postoperative leukocyte count (p <0.05). However, for blood requirements, intraoperative urinary output, and pre- and postsurgical levels of creatinine, we did not find differences. Intraoperative bleeding was lower in the MECC group (p <0.05). Major cardiovascular complications were also lower in this group (p <0.05). CONCLUSIONS: MECC reduces the frequency of major cardiovascular complications, intraoperative bleeding and probably a lower inflammatory systemic response compared with conventional CPB.

Cirugía de revascularización miocárdica con apoyo de un sistema de circulación extracorpórea mínima / Coronary artery bypass grafting surgery with minimal extracorporeal circulation system

Introducción: Para realizar revascularización miocárdica, en la mayoría de los casos se requiere el apoyo de circulación extracorpórea, no exenta de riesgos. El objetivo de esta investigación fue probar la hipótesis de que la circulación extracorpórea mínima ofrece mayores ventajas sobre la circulación extracorpórea convencional en la cirugía de revascularización cardiaca. Material y métodos: Se incluyeron 17 pacientes sometidos a revascularización miocárdica entre el 1 de abril de 2006 y el 31 de agosto de 2009, que se dividieron en dos grupos: uno en el que se utilizó circulación extracorpórea mínima (n = 8) y otro con circulación extracorpórea convencional (n = 9), se comparó la hemorragia perioperatoria, uso de hemoderivados y evolución clínica. Resultados: Se observó diferencia estadísticamente significativa en el conteo de leucocitos en el posoperatorio (p < 0.05). En cuanto a los requerimientos de hemoderivados, diuresis transoperatoria, creatinina prequirúrgica y creatinina a las 24 horas posoperatorio, no se observó diferencia estadísticamente significativa entre los grupos. El sangrado transoperatorio fue menor en el grupo en el que se utilizó circulación extracorpórea mínima (p < 0.05). Las complicaciones cardiovasculares mayores ocurrieron con más frecuencia en los pacientes en los que se utilizó circulación extracorpórea convencional (p < 0.05). Conclusiones: La circulación extracorpórea mínima en revascularización miocárdica reduce la frecuencia de eventos adversos cardiovasculares mayores, el sangrado intraoperatorio y tiende a producir menor respuesta inflamatoria comparada con la circulación extracorpórea convencional.

BACKGROUND: For coronary artery bypass graft (CABG) surgery, cardiopulmonary bypass (CPB) is required for many patients. However, this procedure has several risks. Our objective was to test the hypothesis that the minimal extracorporeal circulation circuit (MECC) is more advantageous than CPB for CABG surgery. METHODS: We analyzed 17 patients submitted to CABG surgery between April 1, 2006 and August 31, 2009. Patients were divided into two groups. In one group, MECC (n = 8) was used and in the other group the conventional CPB circuit (n = 9). Perioperative bleeding, blood requirements and clinical evolution were compared. RESULTS: We observed a statistically significant difference for postoperative leukocyte count (p <0.05). However, for blood requirements, intraoperative urinary output, and pre- and postsurgical levels of creatinine, we did not find differences. Intraoperative bleeding was lower in the MECC group (p <0.05). Major cardiovascular complications were also lower in this group (p <0.05). CONCLUSIONS: MECC reduces the frequency of major cardiovascular complications, intraoperative bleeding and probably a lower inflammatory systemic response compared with conventional CPB.

Autotransfusión en cirugía cardiaca / Autologous blood transfusion in cardiac surgery

Se describe la utilización de transfusión autóloga por depósito previo (TADP) en 75 pacientes con comuniación interauricular o interventricular que requirieron cirugía entre julio de 1992 y septiembre de 1996 en el Centro Médico La Raza. La mayoría correspondió al sexo femenino (93.3 por ciento), la edad promedio fue de 29 años y 64 por ciento perteneció al grupo sanguíneo O factor Rh positivo; 8 por ciento no requirió unidad de TADP, 2.6 por ciento requirió una 2.6 necesitó dos y 86.8 por ciento requirió tres. En 10.6 por ciento se utilizó sangre homóloga adicional. No existieron complicaciones atribuibles a la TADP. El objetivo de evitar la utilización de sangre homóloga se alcanzó en 89.4 por ciento de los casos

Quiste hidatídico pulmonar con ruptura mixta: informe de un caso / Pulmonary hydatid cyst with mixed rupture: a case report

Se estudió una paciente de 21 años, que nació y vive en el Distrito Federal, la cual tuvo un quiste hidatídico pulmonar con apertura mixta a bronquios y pleura. Este es el primer caso que se conoce en México con esta presentación clínica y radiológica. Clínicamente la enferma tuvo tos con expectoración "salada", fiebre, disnea y a la exploración física reveló eritema facial, broncoespasmo bilateral y derrame pleural derecho; la imagen radiológica mostró una lesión parenquimatosa con signo del "doble arco" y derame pleural. Se le realizó una broncoscopia y una punción pleural, las muestras obtenidas mediante estos procedimientos revelaron los ganchos característicos y el parásito. La paciente fue manejada con pleurotomía cerrada durante 53 días y albendazol 10 mg/kg-perso en dos ciclos de 30 días con un intervalo de descanso de 15 días entre uno y otro ciclo. Clínicamente la paciente se encuestra curada a 30 meses de seguimiento