Combined atrial fibrillation ablation and balloon mitral commissurotomy in patients with rheumatic mitral stenosis.

INTRODUCTION: Ablation of atrial fibrillation (AF) is usually not considered in patients with rheumatic mitral stenosis (RMS). We analyzed the results of a combined procedure of AF ablation and percutaneous balloon mitral commissurotomy (PBMC). METHODS: We prospectively included 22 patients with severe RMS to undergo a combined PBMC + AF ablation procedure. Noninvasive mapping of the atria was also performed. A historical sample of propensity-scored matched patients who underwent PBMC alone was used as controls. The primary endpoint was freedom from AF/AT at 1-year. Multivariate analysis evaluated sinus rhythm (SR) predictors. RESULTS: Successful pulmonary vein isolation and electrocardiographic imaging-based drivers ablation was performed in 20 patients following PBMC. At 1-year, 75% of the patients in the combined group were in SR compared to 40% in the propensity-score matched group (p = 0.004). The composite of AF recurrence, need for mitral surgery and all-cause mortality was also more frequent in the control group (65% vs. 30%; p = 0.005). Catheter ablation (odds ratio [OR] 1.58; 95% confidence interval [CI] [1.17-17.37]; p = 0.04) and AF type (OR 1.46; 95% CI [1.05-82.64]; p < 0.001) were the only independent predictors of SR at 1-year. Noninvasive mapping in the combined group showed that the number of simultaneous rotors (OR 2.10; 95% CI [1.41-10.2]; p = 0.04) was the only independent predictor of AF. CONCLUSION: A combined procedure of AF ablation and PBMC significantly increased the proportion of patients in sinus rhythm at 1-year. Noninvasive mapping may help to improve AF characterization and guide personalized AF treatment.

Recomendaciones para la práctica clínica: hipoglucemia en personas con diabetes mellitus / Recommendations for clinical practice: hypoglycemia in people with diabetes mellitus

En la hipoglucemia secundaria, el tratamiento de la diabetes mellitus (DM) se define ante un valor de glucemia por debajo de 70 mg/dl, pudiendo manifestarse por síntomas autonómicos y neuroglucopénicos, con consecuencias a corto y largo plazo, como el deterioro de las funciones cognitivas y el aumento del riesgo cardiovascular, entre otras. La hipoglucemia en personas con DM1 es más frecuente que en aquellas con DM2. Los factores que incrementan su riesgo son: el retraso en la ingesta de comida, el alcohol, el ejercicio intenso, el ayuno y la neuropatía autonómica. Por otro lado, las hipoglucemias inadvertidas se asocian con un mayor riesgo de hipoglucemia grave. Los niños y adultos mayores son un grupo vulnerable a estos eventos que, en muchos casos, presentan síntomas difíciles de distinguir. A su vez, la hipoglucemia durante el embarazo se asocia con mayor riesgo de complicaciones. Otro grupo importante para detectar estos episodios son los pacientes hospitalizados a fin de disminuir la morbimortalidad asociada a los mismos. La calidad de vida está claramente afectada en los pacientes que sufren episodios de hipoglucemia, por lo cual resulta esencial instaurar estrategias de prevención como la educación, el monitoreo glucémico, realizar modificaciones en la dieta y el ejercicio, y ajustar la medicación. El tratamiento, en caso de no presentar pérdida de conciencia, será por vía oral, de lo contrario, se recurrirá a glucosa endovenosa o glucagón intramuscular.

Hypoglycemia due to treatment of diabetes mellitus (DM) is defined by a blood glucose value below 70 mg/dl, which can manifest itself by autonomic and neuroglycopenic symptoms, with short- and long-term consequences, such as impaired cognitive functions and increased cardiovascular risk, among others. Hypoglycemia in people with DM1 is more frequent than in those with DM2. Factors that increase its risk are: delayed food intake, alcohol, intense exercise, fasting and autonomic neuropathy. On the other hand, inadvertent hypoglycemia is associated with an increased risk of severe hypoglycemia. Children and older adults are a vulnerable group to these events that, in many cases, present symptoms that are difficult to distinguish. Hypoglycemia during pregnancy is associated with an increased risk of complications. Another important group to detect these episodes are hospitalized patients in order to reduce the morbimortality associated with them. Quality of life is clearly affected in patients who suffer episodes of hypoglycemia, so it is essential to implement prevention strategies such as education, glycemic monitoring, dietary and exercise modifications, and medication adjustment. Treatment, if there is no loss of consciousness, will be oral, otherwise, intravenous glucose or intramuscular glucagon will be used.

Recomendaciones para la práctica clínica: hipoglucemia en personas con diabetes mellitus / Recommendations for clinical practice: hypoglycemia in people with diabetes mellitus

Resumen En la hipoglucemia secundaria, el tratamiento de la diabetes mellitus (DM) se define ante un valor de glucemia por debajo de 70 mg/dl, pudiendo manifestarse por síntomas autonómicos y neuroglucopénicos, con consecuencias a corto y largo plazo, como el deterioro de las funciones cognitivas y el aumento del riesgo cardiovascular, entre otras. La hipoglucemia en personas con DM1 es más frecuente que en aquellas con DM2. Los factores que incrementan su riesgo son: el retraso en la ingesta de comida, el alcohol, el ejercicio intenso, el ayuno y la neuropatía autonómica. Por otro lado, las hipoglucemias inadvertidas se asocian con un mayor riesgo de hipoglucemia grave. Los niños y adultos mayores son un grupo vulnerable a estos eventos que, en muchos casos, presentan síntomas difíciles de distinguir. A su vez, la hipoglucemia durante el embarazo se asocia con mayor riesgo de complicaciones. Otro grupo importante para detectar estos episodios son los pacientes hospitalizados a fin de disminuir la morbimortalidad asociada a los mismos. La calidad de vida está claramente afectada en los pacientes que sufren episodios de hipoglucemia, por lo cual resulta esencial instaurar estrategias de prevención como la educación, el monitoreo glucémico, realizar modificaciones en la dieta y el ejercicio, y ajustar la medicación. El tratamiento, en caso de no presentar pérdida de conciencia, será por vía oral, de lo contrario, se recurrirá a glucosa endovenosa o glucagón intramuscular.

Abstract Hypoglycemia due to treatment of diabetes mellitus (DM) is defined by a blood glucose value below 70 mg/dl, which can manifest itself by autonomic and neuroglycopenic symptoms, with short- and long-term consequences, such as impaired cognitive functions and increased cardiovascular risk, among others. Hypoglycemia in people with DM1 is more frequent than in those with DM2. Factors that increase its risk are: delayed food intake, alcohol, intense exercise, fasting and autonomic neuropathy. On the other hand, inadvertent hypoglycemia is associated with an increased risk of severe hypoglycemia. Children and older adults are a vulnerable group to these events that, in many cases, present symptoms that are difficult to distinguish. Hypoglycemia during pregnancy is associated with an increased risk of complications. Another important group to detect these episodes are hospitalized patients in order to reduce the morbimortality associated with them. Quality of life is clearly affected in patients who suffer episodes of hypoglycemia, so it is essential to implement prevention strategies such as education, glycemic monitoring, dietary and exercise modifications, and medication adjustment.

Historical development of the anesthetic machine: from Morton to the integration of the mechanical ventilator.

The first anesthetic machines appeared following their public demonstration by Morton in 1846. These initial devices were simple inhalers based on the evaporation of the anesthetic agent. Their main problem was the loss of effectiveness with cooling. More complex inhalers were subsequently developed, in which the main difference was the possibility to provide more than one agent. Moreover, the concentration of the inhaled anesthetic was regulated for greater efficiency. At the beginning of the twentieth century, gas machines emerged, allowing the application of an anesthetic flow independent of the patient's inspiratory effort. These machines incorporated technological advances such as flow meters, carbon dioxide absorption systems and fine adjustment vaporizers. In this period, in the field of thoracic surgery, intraoperative artificial ventilation began to be employed, which helped overcome the problem of pneumothorax associated with open pleura by applying positive pressure. From the 1930s, the gas machines were fitted with a ventilator, and by the 1950s this had become a basic component of the anesthesia system. Later still, in the 1980s, alarm and monitoring systems were incorporated, giving rise to the current generation of workstations.

Tratamiento con radiofrecuencia de la tormenta eléctrica: evolución y seguimiento / Radiofrequency treatment for electrical storm: evolution and monitoring

Resumen Introducción y objetivos: La tormenta eléctrica (TE) se caracteriza por episodios repetidos de taquicardia ventricular o fibrilación ventricular relacionados con mal pronóstico a corto y largo plazos. El objetivo fue evaluar la prevalencia, resultados y supervivencia de los pacientes sometidos a tratamiento intervencionista por TE en un centro de referencia. Métodos: Estudio unicéntrico, observacional y retrospectivo. Se revisaron los procedimientos de ablación por TE y se evaluaron las características basales de los pacientes, tipo de procedimiento, mortalidad total, recurrencia de arritmia, mortalidad cardiovascular y necesidad de trasplante. Resultados: Desde enero de 2009 hasta diciembre de 2016 se realizaron 67 procedimientos (38% de complejos: 19% de ablación endoepicárdica, 7.5% de crioablación epicárdica quirúrgica, 3% de simpatectomía, 3% de inyección coronaria con alcohol; 6% de apoyo con oxigenación con membrana extracorpórea) en 41 pacientes (61% de causa isquémica) por TE. La mortalidad intraprocedimiento fue del 1.5%. La mediana de seguimiento fue de 23.5 meses (RIQ, 14.2-52.7). Tras el primer ingreso por TE (uno o varios procedimientos), la mortalidad a un año fue de 9.8%. La incidencia acumulada de trasplante cardiaco por TE fue de 2.4%. En el análisis multivariado, el riesgo de recurrencias arrítmicas o muerte por cualquier causa fue significativamente mayor en pacientes con arritmias clínicas inducibles (HR, 9.03; p = 0.017). Conclusiones: El tratamiento de pacientes con TE, instituido en un centro de referencia y con experiencia, se relacionó con una tasa baja de recurrencia y supervivencia elevada, con una tasa de trasplante cardiaco por TE muy baja. Ante una recurrencia temprana es recomendable practicar un nuevo procedimiento durante el ingreso.

Abstract Introduction and objective: Electrical storm (ES) is characterized by repeated episodes of ventricular tachycardia or ventricular fibrillation, with poor short and long term prognosis. Our objective was to evaluate the prevalence, results of interventional treatment and survival of patients undergoing interventional treatment for ES in our center. Methods: Retrospective, unicentric and observational study. ES ablation procedures were revised and data regarding baseline characteristics of the patients, type of procedure, total mortality, recurrence of arrhythmia, cardiovascular mortality and the need for transplantation were evaluated. Results: From January 2009 to December 2016, 67 procedures (38% complex procedures: 19% epicardial ablation, 7.5% surgical epicardial crioablation, 3% simpatectomy, 3% coronary alcohol injection, 6% extracorporeal membrane oxygenation support) were performed in 41 patients (61% Ischemic etiology) due to ES. Intraprocedural mortality was 1.5%. The median follow-up was 23.5 months (IQR [14.2-52.7]). After the first admission for ES (one or several procedures), 1-year mortality was 9.8%. The cumulative incidence of cardiac transplantation was 2.4%. The risk of arrhythmic recurrences or death was significantly higher in patients with inducible clinical arrhythmias after ablation (HR: 9.03, p = 0.017). Conclusions: The treatment of patients with ES, performed in a reference center, allows obtaining good rates of recurrence and survival, with very low rates of cardiac transplantation for ES. In the presence of an early recurrence, it is advisable to perform a new procedure during admission.

Predictors of atrial tachyarrhythmias in adults with congenital heart disease.

BACKGROUND: Atrial tachyarrhythmias (ATs) represent the major late complications of congenital heart diseases (CHDs) following surgery. Little is known about the association between echocardiographic parameters and AT. AIMS: This study aimed to investigate a potential correlation among clinical, echocardiographic, and electrocardiographic parameters and AT as well as to analyze outcomes in adults with CHD and AT. METHODS: A retrospective case­control study was performed in adults with CHD. We included 71 patients with AT and 71 control individuals matched by sex, age, and the type of CHD without AT, all from the same institute. Medical records, electrocardiograms, and echocardiograms were reviewed. Adverse cardiovascular events were recorded and defined as cardiovascular mortality, admission for heart failure, or stroke. The univariate and multivariate logistic regression analysis of possible risk factors and the Kaplan-Meier analysis of adverse cardiovascular events were performed. RESULTS: Subpulmonary ventricular systolic pressure≥40 mm Hg (hazard ratio [HR], 6.8; 95% CI, 2.4-18; P <0.001), right atrial dilatation≥21 cm2 (HR, 3.1; 95% CI, 1.2-7.6; P = 0.01), and significant tricuspid regurgitation (HR, 4; 95% CI, 1.3-10; P = 0.02) were identified as the main risk factors for AT. Patients with AT had worse outcomes, more frequently developed adverse cardiovascular events (86% vs 14%; P <0.01), and exhibited a 58% event­free survival rate compared with 98% of the patients without AT after 8 years of follow­up (log rank, 6.6; P = 0.01). CONCLUSIONS: Among patients with CHD, the main risk factors for AT include right atrial dilatation, high subpulmonary ventricular systolic pressure, and significant tricuspid regurgitation. The presence of AT may increase the risk of adverse cardiac events.

I Jornadas conjuntas del comité de graduados y el comité de hipertensión arterial y otros factores de riesgo cardiovascular. XVIII jornadas del comité de graduados: "enfermedad cardiovascular y diabetes" / I Joint meeting of the graduate committee and the committee on arterial hypertension and other cardiovascular risk factors. XVIII meeting of the graduate committee: "cardiovascular disease and diabetes"

El objetivo de estas Jornadas Conjuntas intercomités de Graduados y de Hipertensión Arterial y otros Factores de Riesgo Cardiovascular fue realizar una revisión bibliográfica del tema: "Enfermedad cardiovascular y diabetes". Para ello, se dividió a los 43 participantes en tres mesas de trabajo que realizaron la revisión y actualización de los siguientes temas: • Mesa 1: Diabetes mellitus tipo 1 y enfermedad cardiovascular. • Mesa 2: Insuficiencia cardíaca y diabetes mellitus tipo 2. • Mesa 3: Efectos cardiovasculares de los fármacos antidiabéticos.

Mesa 3: Efectos cardiovasculares de fármacos antidiabéticos / Table 3: Cardiovascular effects of anti-diabetic drugs

Los eventos cardiovasculares representan la mayor complicación de la diabetes. La evidencia sugiere que la metformina mejora los resultados cardiovasculares en pacientes con diabetes, especialmente en el United Kingdom Prospective Diabetes Study (UKPDS) y otros estudios posteriores, por distintos mecanismos. Hay pocos estudios de seguridad cardiovascular para sulfonilureas aunque no tendrían un perfil seguro a este nivel. La gliclazida parece ser la de mejor performance de las drogas de este grupo. Algo similar ocurre con las meglitinidas, para las cuales los datos indican que no aumentarían el riesgo pero tampoco mejorarían la incidencia de eventos cardiovasculares. Las tiazolidinedionas son las drogas más cuestionadas, aunque los estudios y metaanálisis son contradictorios no habría dudas que aumentan el riesgo de insuficiencia cardíaca. Los inhibidores de la DPPIV mostraron resultados neutros a excepción de saxagliptina que aumentaría el riesgo de internación por insuficiencia cardíaca. Existen datos convincentes que los inhibidores de los receptores SGLT-2 a nivel renal y los análogos del GLP-1 intestinal tienen efectos positivos a nivel cardiovascular, con algunas diferencias entre los integrantes de esta familia. En cuanto a las insulinas, los estudios sugieren que tanto los análogos lentos como rápidos tendrían un mejor perfil cardiovascular, ligado principalmente a la menor incidencia de hipoglucemias severas, que insulina NPH y regular respectivamente.

Cardiovascular events represent the greatest complication of diabetes. Evidence suggests that metformin improves CV outcomes in patients with diabetes, especially in the United Kingdom Prospective Diabetes Study (UKPDS) and other subsequent studies, by different mechanisms. There are few cardiovascular safety studies for sulfonylureas although they would not have a safe profile at this level. Gliclazide appears to be the best performing drug in this group. Something similar occurs with meglitinides for which the data indicates that they would not increase the risk but neither would they improve the incidence of cardiovascular events. Thiazolidinediones are the most questioned drugs, although the studies and meta-analyzes are contradictory, there would be no doubt that they increase the risk of heart failure. DPPIV inhibitors showed neutral results except for saxagliptin, which would increase the risk of hospitalization for heart failure. There is convincing data that SGLT-2 receptor inhibitors at the renal level and intestinal GLP-1 analogues have positive effects at the cardiovascular level with some differences between the members of these families. Regarding insulins, studies suggest that both slow and fast analogues would have a better cardiovascular profile, mainly linked to the lower incidence of severe hypoglycemia, than NPH and regular insulin, respectively

Historia de la ventilación mecánica. De la Antigüedad a Copenhague 1952 / The history of mechanical ventilation

The aim of mechanical ventilation is to substitute physiological respiratory function. The boom of mechanical ventilation came during the XVIII century with the development of Reanimation Societies in Europe, who promoted the use of positive pressure ventilation modes. This type of ventilation caused new complications due to excessive positive pressure in the airway. Therefore, during the XIX century negative pressure ventilation predominated, which became essential during the second half of the 19th century and first half of the 20th century. Positive pressure ventilation was relegated to operating rooms until 1952, when it was imposed over negative pressure ventilation during the Copenhagen polio epidemic. Björn Ibsen contributed significantly to this change of ventilation paradigm, which led to the latest ventilation strategies and the development of the actual intensive care units.

Cryoablation for Perinodal Arrhythmia Substrates in Patients With Congenital Heart Disease and Displaced Atrioventricular Conduction Systems.

OBJECTIVES: The purpose of this study was to assess the safety and efficacy of cryoablation for perinodal substrates in patients with congenital heart disease (CHD) and a displaced atrioventricular (AV) conduction system or an AV conduction system location that was difficult to predict. BACKGROUND: Catheter ablation for perinodal arrhythmias in patients with CHD may incur higher risks due to unconventional or difficult to predict locations of the AV conduction system. Cryoablation carries theoretical advantages for such patients but has not been studied in this setting. METHODS: A total of 35 patients with CHD underwent cryoablation for perinodal substrates at the Montreal Heart Institute between 2006 and 2016. Ten of these patients, age 33 ± 13 years, 60% male, had AV conduction systems that were displaced or of uncertain location and underwent cryoablation (6-mm electrode-tip catheter) for 12 perinodal arrhythmias: AV nodal re-entrant tachycardia (n = 4), non-automatic focal atrial tachycardia (n = 4), septal intra-atrial re-entrant tachycardia (n = 3), and para-Hisian automatic focal atrial tachycardia (n = 1). Four patients had single-ventricle physiology and had undergone Fontan palliation (3 atriopulmonary and 1 intracardiac total cavopulmonary connection), 4 underwent repair of AV septal defects, 1 had congenitally corrected transposition of the great arteries (TGA), and 1 had TGA with a Mustard baffle. RESULTS: Cryoablation was acutely successful in 9 of 12 targeted arrhythmias (75%) with no procedural complication. Crossover to radiofrequency ablation successfully eliminated the remaining 3 arrhythmias at sites deemed safe by cryoablation, with no complication. Over a follow-up period of 26 (interquartile range: 15 to 64) months, 1 of 9 successfully cryoablated arrhythmias recurred. CONCLUSIONS: Cryoablation is feasible, safe, and moderately effective for perinodal arrhythmia substrates in patients with various forms of CHD associated with AV conduction systems that are displaced or in locations that cannot be reliably predicted.

Mesa 3: Diabetes Mellitus Tipo 2 y actividad física / Table 3: Type 2 diabetes and physical activity

La prevalencia de diabetes mellitus (DM) actividad física es cada vez mayor asociada a bajos niveles de actividad física (AF) y aumento de sobrepeso-obesidad. Los beneficios de la AF incluyen la prevención de la DM, reducción de hemoglobina glicosilada y glucemia postprandial, mejoría del perfil cardiovascular (descenso Presión arterial y triglicéridos, aumento de colesterol HDL), descenso significativo de biomarcadores proinflamatorios. Además, la AF mejora la disfunción sexual, la función endotelial, el óxido nítrico biodisponible y la insulinosensibilad, incrementa la testosterona, mejora el humor y la autoestima, la ansiedad y la depresión. El ejercicio incrementa la producción de glucosa, la secreción de insulina compensatoria está alterada y se exacerba por una mayor secreción de catecolaminas. Las personas con insulinopenia marcada tienen riesgo de cetosis. El aumento de hipoglucemias está dado por una mayor captación de glucosa. La AF mejora la polineuropatía y la neuropatía autonómica cardíaca, previene la enfermad renal crónica y se asocia a menores niveles de retinopatía diabética. En pacientes con retinopatía preproliferativa y proliferativa o degradación macular, se desaconsejan las actividades que aumentan considerablemente la presión intraocular. Está contraindicado el ejercicio en caso de hemorragia vítrea. El requerimiento energético depende del tipo, intensidad y duración del ejercicio. Se debe considerar el cuidado del pie. Las recomendaciones son disminuir el tiempo sedentario, ejercicio aeróbico al menos 150 min/semana y ejercicio de resistencia. Al aumentar la intensidad o ante riesgo elevado se debe realizar chequeo que incluya electrocardiograma y test de esfuerzo. Considerar ecocardiograma bidimensional y doppler

Pediatric Catheter Ablation: Characteristics and Results of a Series in a Tertiary Referral Hospital.

INTRODUCTION AND OBJECTIVES: Catheter ablation has become the treatment of choice in an increasing number of arrhythmias in children and adolescents. There is still limited evidence of its use at a national level in Spain. The aim was to describe the characteristics and results of a modern monocentric series form a referral tertiary care centre. METHODS: Retrospective register of invasive procedures between 2004 and 2016 performed in patients under 17 years and recorded clinical characteristic, ablation methodology and acute and chronic results of the procedure. RESULTS: A total of 291 procedures in 224 patients were included. Median age was 12.2 years, 60% male. Overall, 46% patients were referred from other autonomous communities. The most frequent substrates were accessory pathways (AP) (70.2%,>50% septal AP localization) and atrioventricular nodal reentrant tachycardia (AVNRT) (15.8%). Congenital and acquired heart disease was frequent (16.8%). Cryoablation was used in 35.5% of the cases. Overall acute success of the primary procedure was 93.5% (AP 93.8%; AVNRT 100%). Redo procedures after recurrence were performed in 18.9% of all substrates, with a long-term cumulative efficacy of 98.4% (AP 99.3%; AVNRT 100%). One (0.37%) serious complication occurred, a case of complete atrioventricular block. CONCLUSIONS: Our study replicated previous international reports of high success rates with scarce complications in a high complexity series, confirming the safety and efficacy of pediatric catheter ablation in our environment performed at highly experienced referral centers.

Safety and efficacy of cryoablation vs. radiofrequency ablation of septal accessory pathways: systematic review of the literature and meta-analyses.

Aims: Radiofrequency ablation (RFA) of septal accessory pathways (APs) is associated with a significant rate of first procedure failures and complications. Cryoablation is an alternative energy source but there are no studies comparing both ablation techniques. We aimed to systematically review the literature and compare the efficacy and safety of cryoablation vs. RFA of septal APs. Methods and results: We conducted two separate meta-analysis of cryoablation and RFA of septal APs and calculated the global estimates of the efficacy and safety. Sixty-four articles were included: 38 articles reporting RFA and 27 articles reporting cryoablation procedures. Additionally, we included the previously non-published cryoablation registry of septal APs performed at our institution. Overall, 4244 septal APs constitute our study population, 3495 in the RFA cohort and 749 in the cryoablation cohort. Acute procedural success rate of cryoablation was 86.0% (95% CI 81.6-89.4%) and RFA 89.0% (95% CI 86.8-91.0%). Recurrence rate of cryoablation was 18.1% (95% CI 14.8-21.8%) and RFA 9.9% (95% CI 8.2-12.0%). Long-term success rate after multiple ablation procedures of cryoablation was 75.9% (95% CI 68.2-82.3%) and RFA 88.4% (95% CI 84.7-91.3%). There were no reported cases of persistent atrioventricular block (AVB) with cryoablation and 2.7% (95% CI 2.2-3.4%) with RFA. Conclusion: Studies of RFA for treatment of septal APs report higher efficacy rates than do studies using cryoablation, but a significantly higher rate of AVB.

Natural History and Clinical Predictors of Atrial Tachycardia in Adults With Congenital Heart Disease.

BACKGROUND: Atrial tachycardias (ATs) are a significant source of morbidity in adults with congenital heart disease (CHD). This study evaluates the incidence and clinical predictors of AT in a cohort of patients with CHD. METHODS AND RESULTS: We included 3311 adults (median age at entry 22.6 years, 50.6% males) with CHD (49% simple, 39% moderate, and 12% complex) prospectively followed up in a tertiary center for 37 607 person-years. Predictors of AT were identified by multivariable Cox regression analysis accounting for left truncation. An external validation was performed in a contemporary cohort of 1432 patients. Overall, 153 (4.6%) patients presented AT. AT burden was highest in complex CHD, such as single ventricle (22.8%) and d-transposition of the great arteries (22.1%). Hazard rates of AT across lifetime, age at presentation, and the time lapse between surgery and the first AT episode varied among the most common CHD. Independent risk factors for developing AT were univentricular physiology, previous intracardiac repair, systemic right ventricle, pulmonary hypertension, pulmonary regurgitation, pulmonary atrioventricular valve regurgitation, pulmonary and systemic ventricular dysfunction. At the age of 40 years, AT-free survival in patients with 0, 1, 2, and ≥3 risk factors was 100%, 94%, 76%, and 50%, respectively. These findings were confirmed in the validation cohort. CONCLUSIONS: Natural history of AT differed among the most common forms of CHD. Simple clinical parameters, easily obtained by noninvasive means, were independent predictors of AT in adults with CHD. Although risk was negligible in patients without any of these factors, their addition progressively increased AT burden.

Current Indications for Implantable Cardioverter Defibrillators in Non-Ischemic Cardiomyopathies and Channelopathies.

Current indications for implantable cardioverter defibrillators (ICDs) in patients with channelopathies and cardiomyopathies of non-ischemic origin are mainly based on non-randomized evidence. In patients with nonischemic dilated cardiomyopathy (NIDCM), there is a tendency towards a beneficial effect on total mortality of ICD therapy in patients with significant left ventricular (LV) dysfunction. Although an important reduction in sudden cardiac death (SCD) seems to be clearly demonstrated in these patients, a net beneficial effect on total mortality is unclear mostly in cases with good functional status. Risk stratification has been changing over the last two decades in patients with hypertrophic cardiomyopathy (HCM). Its risk profile has been delineated in parallel with the beneficial effect of ICD in high risk patients. Observational results based on "appropriate" ICD interventions do support its usefulness both in primary and secondary SCD prevention in these patients. Novel risk models quantify the rate of sudden cardiac death in these patients on individual basis. Less clear risk stratification is available for cases of arrhythmogenic right ventricular cardiomyopathy (ARVC) and in other uncommon familiar cardiomyopathies. Main features of risk stratification vary among the different channelopathies (long QT syndrome -LQTS-, Brugada syndrome, etc) with great debate on the management of asymptomatic patients. For most familiar cardiomyopathies, ICD therapy is the only accepted strategy in the prevention of SCD. So far, genetic testing has a limited role in risk evaluation and management of the individual patient. This review aims to summarize these criticisms and to refine the current indications of ICD implantation in patients with cardiomyopathies and major channelopathies.

Trastornos de la fertilidad en el hombre con diabetes tipo 1 y 2 / Fertility alterations in men wiht type 1 and 2

La diabetes mellitus (DM) es una de las mayores amenazas para la Salud Publica en las sociedades modernas. Si bien durante varios años se sugirió que la DM no tenía efecto significativo en la función reproductiva masculina, esta visión fue cambiando. La creciente incidencia de la DM a nivel mundial afectara a cada vez más hombres y de menor edad, y por lo tanto podría afectar su potencial reproductivo.

Comparison of the safety and feasibility of arrhythmia ablation using the Amigo Robotic Remote Catheter System versus manual ablation.

The aim of this study is to evaluate the safety and feasibility of using the Amigo Remote Catheter System (RCS) in arrhythmia ablation procedures. Because Amigo allows the physician to operate all catheter function outside of the radiation field, operator exposure time was also evaluated. This is a nonrandomized, prospective clinical trial conducted at 1 site (identifier: NCT01834872). The study prospectively enrolled 50 consecutive patients (mean age 59 ± 15 years, 72% men) with any type of arrhythmia (23 atrial fibrillation ablation, 12 common atrial flutters, 10 patients with other supraventricular tachycardia, 4 ventricular tachycardia, and 1 patient with palpitations with no arrhythmia induced) referred for catheter ablation, in which we used RCS. Fifty matched ablation procedures (mean age 57 ± 14 years, 70% men) performed during the same time period, without RCS, were enrolled into the control group. Acute ablation success was 96% with RCS and 98% in the manual group. In only 2 cases, the physician switched to manual ablation (1 ventricular tachycardia and 1 accessory pathway) to complete the procedure. There were no complications related to the use of RCS. No differences were observed in total procedure time, total fluoroscopy time, or total radiofrequency delivery compared with the manual group. In procedures performed with RCS, the operator's fluoroscopy exposure time was reduced by 68 ± 16%. In conclusion, arrhythmia ablation with RCS is safe and feasible. Furthermore, it significantly reduces operator's exposure to radiation.

Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).

BACKGROUND: Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. METHODS AND RESULTS: Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0-43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). CONCLUSION: Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. CLINICAL TRIAL REGISTRATION INFORMATION: NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).

El gas de los monopolios: análisis de la política de hidrocarburos en Bolivia / sss

Contiene: la propiedad de los hidrocarburos, regalias y participaciones, politica de precios de hidrocarburos, exportación - industrialización, YPFB.