RESUMEN
We evaluated the clinical value of a single measurement of high-sensitivity C-reactive protein (hs- CRP) in patients presenting to the emergency department with chest pain. We screened 408 consecutive patients of whom 292 comprised the final cohort for this study. Hs-CRP measured in the emergency department (ED) in patients presenting with chest pain and admitted for evaluation of acute myocardial infarction was neither sensitive nor specific in predicting acute myocardial infarction, myocardial ischemia on SPECT imaging, need for coronary revascularization, or cardiovascular or all-cause rehospitalization at 30 days. In addition, use of a specific CRP cut off >1 was not associated with an increase in all-cause rehospitalization at 30 days.
Asunto(s)
Proteína C-Reactiva/análisis , Dolor en el Pecho/sangre , Servicio de Urgencia en Hospital/organización & administración , Isquemia Miocárdica/sangre , Isquemia Miocárdica/diagnóstico , Enfermedad Aguda , Anciano , Fármacos Cardiovasculares/administración & dosificación , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Readmisión del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/estadística & datos numéricos , Sensibilidad y Especificidad , Índice de Severidad de la EnfermedadRESUMEN
Background: Mitral regurgitation (MR) in the context of left ventricular systolic dysfunction is often designated as functional, with emphasis on the underlying cardiomyopathy leading to malcoaptation of the 'otherwise normal valve'. Case summary: A 63-year-old male with ischaemic cardiomyopathy (left ventricular ejection fraction 20%) presented with intractable heart failure in need of inotropic support and could not be stepped down from an ICU hospital setting. Functional MR, graded as moderate on transthoracic echocardiography, was initially not considered as pertinent to the clinical condition and options discussed included initiation of dialysis for volume management, chronic inotropic support, and palliative measures. However, a re-examination of the mitral valve by transoesophageal echo revealed severe regurgitation from annular dilatation and restricted mobility during systole. Transcatheter edge to edge repair utilizing the PASCAL device resulted in marked reduction of MR followed by an abrupt clinical improvement, weaning off inotropes and discharge home 4 days later. At four-year follow-up, the patient is stable on optimal heart failure therapy. Discussion: For many patients with heart failure and underlying cardiomyopathy, the presence of significant functional MR, instead of a 'bystander' disease, actually becomes the dominant driver of symptoms and compounds the low cardiac output state. In these patients, the term 'functional' MR becomes a misnomer, as in fact the so called 'otherwise normal' mitral valve is actually a severely dysfunctional valve with a wide malcoaptation zone. Transcatheter edge to edge repair is an effective bailout procedure for patients with low cardiac output and disproportionate severe functional MR.
RESUMEN
OBJECTIVES: To evaluate the long-term (≥2 years) outcomes following transcatheter tricuspid valve repair (TTVr) with the FORMA Transcatheter Tricuspid Valve Repair System (Edwards Lifesciences, Irvine, California). BACKGROUND: Scarce data exist on long-term outcomes following TTVr. METHODS: This multicenter experience included patients with severe tricuspid regurgitation (TR) who underwent TTVr with the FORMA system at 4 centers under a compassionate clinical use program. Data were collected at baseline, 30 days, and 1 year, and yearly thereafter. RESULTS: Nineteen patients (76 ± 9 years of age, 74% women, mean EuroSCORE II [European System for Cardiac Operative Risk Evaluation] 9.2 ± 5.6%) with functional TR were included. Procedural success was achieved in 17 (89%) patients and there were no cases of 30-day mortality. At a median follow-up of 32 (interquartile range: 24 to 36) months, 4 (24%) patients had died (3 from terminal heart failure, 1 from sepsis) and 3 (18%) patients required rehospitalization for heart failure. There was 1 device-related thrombosis and 1 pulmonary embolism, both in the setting of subtherapeutic oral anticoagulation. Less than severe TR was observed at echocardiography in 67% of patients at the 2- to 3-year follow-up. Among 15 successfully implanted patients with at least 24-month follow-up, significant improvements in New York Heart Association functional class (p < 0.001), 6-min walk test (+54 m; p = 0.016) and Kansas City Cardiomyopathy Questionnaire score (+16 points; p = 0.016) were observed, compared with baseline. CONCLUSIONS: TTVr using the FORMA system showed favorable long-term safety profile in high-surgical-risk patients, with sustained functional improvement and acceptable TR reduction up to 3 years.
Asunto(s)
Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Hemodinámica , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Anciano , Anciano de 80 o más Años , Canadá , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Ensayos de Uso Compasivo , Europa (Continente) , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Diseño de Prótesis , Recuperación de la Función , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/mortalidad , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
Noncompaction of the ventricular myocardium is a rare form of cardiomyopathy that has been described since the early 1990s. However, noncompaction remains frequently overlooked, in part due to the limited awareness of its unique clinical and imaging characteristics. Contemporary diagnosis has been facilitated by the introduction of specific morphologic criteria by echocardiography and cardiac magnetic resonance. Management issues revolve around the management of heart failure, arrhythmias, and thromboembolic events in order to prevent the significant morbidity and even mortality that has been associated with this entity. Finally, the genetics of noncompaction have been diverse and an issue of clinical importance as it relates to screening of first-degree relatives of affected patients. Two recent cases are presented and many of the contemporary issues in diagnosis and management, based on an extensive review of the literature, are addressed.
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Cardiomiopatías/diagnóstico , Cardiomiopatías/terapia , Taquicardia Ventricular/terapia , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Cardiomiopatías/complicaciones , Desfibriladores Implantables , Ecocardiografía , Femenino , Humanos , Imagen por Resonancia Cinemagnética , Masculino , Persona de Mediana Edad , Taquicardia Ventricular/etiología , Disfunción Ventricular Izquierda/terapiaRESUMEN
Thrombosis of intracoronary stents is a major complication associated with significant morbidity and mortality. Of concern are case reports of late (more than six months from deployment) drug-eluting stent thrombosis temporally associated with discontinuation of antiplatelet therapy and when stent endothelialization was presumed to be complete. In certain patients it appears that vascular healing at the stented segments is incomplete with increased susceptibility to late thrombosis. We report two cases of late stent thrombosis occuring more than one year after stent deployment and within weeks of discontinuation of clopidogrel. A review of the literature is presented to identify clinical and angiographic predictors of increased risk.
Asunto(s)
Trombosis Coronaria/etiología , Infarto del Miocardio/etiología , Inhibidores de Agregación Plaquetaria/administración & dosificación , Stents , Trombosis/etiología , Ticlopidina/análogos & derivados , Anciano de 80 o más Años , Aspirina/uso terapéutico , Clopidogrel , Trombosis Coronaria/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Inhibidores de Agregación Plaquetaria/uso terapéutico , Radiografía , Trombosis/terapia , Ticlopidina/administración & dosificación , Ticlopidina/efectos adversos , Ticlopidina/uso terapéutico , Factores de Tiempo , UltrasonografíaAsunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Cateterismo Cardíaco , Grecia , Humanos , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Diseño de Prótesis , Resultado del TratamientoRESUMEN
PURPOSE: We sought to identify certain clinical characteristics associated with a poor clinical outcome in patients acutely infected with Influenza A. METHODS: We performed a retrospective chart review of inpatients with acute Influenza A infection comparing a poor outcome group (POG; n=27), defined as patients who died and/or developed respiratory failure or shock, with a usual outcome group (UOG; n=105). RESULTS: Compared with the UOG, the POG had a significantly greater percentage of patients with: a history of chronic obstructive pulmonary disease (41% vs 20%), coronary artery disease (63% vs 38%), congestive heart failure (44% vs 23%), transient ischemic attack (TIA) or stroke (44% vs 21%), chronic renal insufficiency (22% vs 8%) and dialysis (11% vs 1%). Shortness of breath as a chief complaint (74% vs 44%), lower initial oxygen saturations (0.86 vs 0.92), as well as higher mean respiratory rates (28/minute vs 22/minute) occurred more frequently in the POG. The POG also had a greater frequency of CHF/ vascular congestion (26% vs 8%), and interstitial involvement (22% vs 6%) on admission chest roentgenogram. Independent predictors of poor outcome identified by multivariate analysis included low oxygen saturation on admission, history of TIA or stroke, and history of dialysis. CONCLUSIONS: The presence of certain comorbidities as well as clinical and radiographic evidence of respiratory compromise on admission may be helpful in identifying high-risk patients acutely infected with Influenza A.
Asunto(s)
Virus de la Influenza A , Gripe Humana , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/epidemiología , Comorbilidad , Humanos , Gripe Humana/epidemiología , Gripe Humana/fisiopatología , Pacientes Internos/estadística & datos numéricos , Fallo Renal Crónico/epidemiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Consumo de Oxígeno , Pronóstico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Respiración , Estudios Retrospectivos , Riesgo , Factores de TiempoAsunto(s)
Infecciones por Mycobacterium/complicaciones , Infecciones por Mycobacterium/tratamiento farmacológico , Marcapaso Artificial/microbiología , Anciano de 80 o más Años , Antiinfecciosos/uso terapéutico , Cefepima , Cefalosporinas/uso terapéutico , Quimioterapia Combinada , Humanos , Inyecciones Intravenosas , Masculino , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Vancomicina/uso terapéuticoRESUMEN
Transcatheter aortic valve implantation is emerging as a promising, effective therapy for high-risk patients not eligible to undergo surgical aortic valve replacement. Infection complications have only rarely been reported. We report a case of probable endocarditis caused by coagulase-negative Staphylococcus following repeated attempts at implantation of a CoreValve bioprosthesis.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Endocarditis/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Infecciones Relacionadas con Prótesis/etiología , Reoperación/efectos adversos , Infecciones Estafilocócicas/etiología , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Bioprótesis/efectos adversos , Bioprótesis/microbiología , Cateterismo Cardíaco , Ecocardiografía Transesofágica , Endocarditis/diagnóstico , Endocarditis/tratamiento farmacológico , Estudios de Seguimiento , Prótesis Valvulares Cardíacas/microbiología , Humanos , Masculino , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/tratamiento farmacológico , Staphylococcus epidermidis/aislamiento & purificaciónRESUMEN
BACKGROUND: Endocarditis complicating central venous catheter blood stream infection (CVC-BSI) is a serious complication and is being seen with increasing frequency. METHODS: All patients discharged from our institution with International Classification of Disease (ICD-9) codes of endocarditis and CVC-BSI were identified. The medical records of those meeting our inclusion criteria were reviewed. RESULTS: From October 1, 1998 until December 31, 2006, 24 patients were identified with inpatient mortality of 20.8%. Nine cases were nosocomial and 15 were non-nosocomial. The most common comorbidities were diabetes mellitus (45.8%), chronic kidney disease (58.4%), prior valvular abnormalities (37.5%), and multiple prior hospitalizations (65.2%). There were 13 external lines, 9 tunneled lines, and 2 implantable ports. Responsible microorganisms included Staphylococcus aureus in 54.6%, coagulase-negative staphylococci in 37.5%, Candida species (spp.) in 16.6%, and enterococci in 12.5%. Five cases were polymicrobial. The line tip was within the right atrium (RA) in 37.5%, the superior vena cava (SVC)-RA junction in 20.8%, the SVC in 33.3%, and the pulmonary artery in 4.2% of patients. Sites of endocardial involvement were the aortic valve in 6 patients, mitral valve in 7 patients, tricuspid valve in 6 patients, right atrial wall in 11 patients, and pacemaker wire in 2 patients. Isolated right-sided involvement occurred in 50% of cases, isolated left-sided in 33.4%, and bilateral involvement in 16.6%. Transesophageal echocardiography (TEE) was necessary for diagnosis in 10 cases (41.6%). CONCLUSIONS: Endocarditis complicating CVC-BSI more often involves right-sided structures, with catheter tips in or near the right atrium, frequently requires TEE for diagnosis, and has significant inpatient mortality.
Asunto(s)
Bacteriemia/etiología , Infecciones Relacionadas con Catéteres/complicaciones , Cateterismo Venoso Central/efectos adversos , Endocarditis Bacteriana/complicaciones , Antibacterianos/uso terapéutico , Infecciones Relacionadas con Catéteres/terapia , Comorbilidad , Infección Hospitalaria/complicaciones , Ecocardiografía Transesofágica , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/terapia , Femenino , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/microbiología , Válvulas Cardíacas/diagnóstico por imagen , Válvulas Cardíacas/microbiología , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Aneurysmal coronary artery disease is frequently encountered in clinical cardiology practice. Although more commonly associated with atherosclerosis, a variety of other acquired (eg, inflammatory, infectious, iatrogenic) or congenital causes have been identified. Recent research on the pathogenesis of coronary aneurysms has yielded interesting results. Advances in imaging have also provided new insights as to the nature of angiographic coronary aneurysms. Critical assessment of the abnormal flow dynamics and pathophysiology of aneurysms has been performed and there is an improved understanding of the associated complications. We present an extensive review of the recent literature highlighting the major advances in the field.