Public insurance program impact on catastrophic health expenditure on acute myocardial infarction.

OBJECTIVE: ST-segment elevation myocardial infarction (STEMI) has an important economic burden that poised the urgent need to evaluate its catastrophic medical expense. This study evaluates the first 5 years of the national health initiative called Popular Insurance (PI) at the National Institute of Cardiology in Mexico. STUDY DESIGN: Retrospective data analysis. METHODS: STEMI patients with (n=317) and without (n=260) PI were selected. Analysed variables included socio-economical context, management care, cost evaluation and three outcomes (mortality, hospital readmission and therapeutic adherence). Descriptive statistical analyses, Kaplan-Meier survival and Support Vector Machine models were used accordingly. RESULTS: Treatment costs were higher for PI-covered individuals (P=0.022) and only 1.89% of them remained in debt, in contrast to 16.15% of those without PI. Statistically significant differences were found in relation to days in hospital wards (P<0.001), imaging studies (P<0.001) and surgical materials (P=0.04). Survival analysis (P=0.44) and therapeutic adherence (P=0.38) showed no differences. Hospital readmission was predicted with an 81.97% accuracy. The most important predictive variables included were stent type, number of days at the coronary care unit and hospital wards. CONCLUSIONS: The PI has proven to be a successful program where no differences were found in terms of health care and survival, whereas it provides timely financial support for families facing catastrophic health challenging events.

Levels of uric acid may predict the future development of pulmonary hypertension in systemic lupus erythematosus: a seven-year follow-up study.

OBJECTIVE: The objective of this paper is to assess whether pulmonary hypertension (PH) may be detected at one point in time or longitudinally predicted by serum uric acid (sUA) levels in systemic lupus erythematosus (SLE). METHODS: We conducted a post-hoc analysis of a long-term followed cohort of Mexican SLE patients. Echocardiography-based definitions of PH by the ESC/ERS/ISHLT and its associations with clinical and laboratory data on enrollment were studied. Especially, the impact that sUA levels at baseline may have on the future development of PH in patients with normal pulmonary artery systolic pressure (PASP) was explored. RESULTS: Out of the 156 SLE patients originally enrolled in the cohort, 44 met the inclusion criteria for the present study and were grouped as having (n =10) or not having (n = 34) PH. At baseline, sUA levels of 5.83 ± 1.79 and 5.82 ± 1.97 mg/dl (p = ns) were found in patients with and without PH, respectively. No association between PASP and other markers was found. In patients with normal PASP, the presence of sUA ≥ 7 mg/dl at baseline predicted future development of PH (relative risk 8.5, 1.0009 to 72; p = 0.04). CONCLUSION: In SLE, sUA levels at one point in time are useless to detect PH. However, steady hyperuricemia may predict the future development of PH in patients with normal PASP at baseline.

Cryptogenic stroke in young patients: long-term prognosis and recurrence.

BACKGROUND: Around 40% of strokes in young people are labelled as infarcts of undetermined cause. The aim of this study was to determine the image characteristics, the long-term functional outcome and recurrence after cryptogenic ischaemic stroke. METHODS: We studied ninety-eight patients under 45 years of age during a median follow up of 54 months (range 12-238), with ischaemic stroke of undetermined cause. We registered vascular risk factors, clinical syndrome, laboratory and imaging results. We used Rankin disability score to assess functional outcome. The cases were evaluated with intracranial and extracranial vascular imaging studies, echocardiogram, and at least two determinations of prothrombotic states. RESULTS: In our hospital 11% of the patients with cerebral infarction under 45 years of age were labelled as cryptogenic. The mean age of the cases was 39.5 ± 5, 48 (49%) were women, 6 (6%) had arterial hypertension, 7 (7%) prior history of migraine, 32 (33%) were active smokers, 11 (11%) had hypercholesterolemia, and 11 (11%) had alcoholism. All cases were treated with aspirin. We observed good functional outcome (Rankin 0-2) in 65 (65%) cases. The anterior circulation was the most affected (partial in 56%, total in 12%). Infarction was unique in 87 (88%) cases. Recurrence was observed in 4 (4%) cases. CONCLUSIONS: In this study cryptogenic cerebral infarctions were mostly single, had low recurrence and good functional outcome in the long-term follow-up. Total anterior circulation infarctions correlated with poor outcome.

Anatomic correlation of left atrial appendage by 3-dimensional echocardiography.

The adequate study of the left atrial appendage is an echocardiographic challenge. The purpose of this study was to assess the ability of 3-dimensional echocardiography in reconstructing this potentially complex structure.

[Transesophageal echocardiographic findings in patients under 40 years of age with cerebrovascular event]. / Hallazgos ecocardiográficos transesofágicos en pacientes menores de 40 años con evento vascular cerebral.

UNLABELLED: The potential cardioembolic sources for ischemic stroke in patients younger than 40 years could be asymptomatic. The purpose of this study is to justify routine implementation of transesophageal echocardiography (TEE) in the study of young patients with ischemic stroke. MATERIAL AND METHODS: 34 patients younger than 40 years with ischemic stroke were studied with TEE complemented with contrast study, looking for potential cardioembolic sources or intracardiac shunts. RESULTS: 19 patients were male and 15 female with ages between 18-40 years (average 31 years). None had cardiac signs or symptoms. Eleven anomalies were detected in 20 patients (58.8%); of these, only 3 were considered as probably coursing with cardioembolic sources: patent foramen ovale (PFO), mitral valve prolapse, and ventricular enlargement, which were found in 12 patients (35.29%). In patients with cardiovascular anomalies, we found a hypercoagulable state, associated in eight patients with PFO (four patients), two with valvular thickening, and two with valvular nodules. CONCLUSIONS: In patients younger than 40 years with ischemic stroke, TEE is useful in detecting direct and indirect cardiac sources of embolism, even in those patients with unsuspected cardiac disease.

[Echocardiography advances in infarction of the right ventricle]. / Avances ecocardiográficos en el infarto del ventrículo derecho.

This review describes echocardiographic findings in patients with inferior myocardial infarction and right ventricular extension. Transthoracic echocardiography has limitations to explore some wall segments of the right ventricle, especially the apical ones, as well as in the evaluation of the right atrial wall motion; further more, this technique offers poor information because this kind of patient frequently has a deficient thoracic acoustic window. Transesophageal echocardiography is the best non-invasive technique because it allows to evaluate all the right chamber segments; when complemented with the administration of dobutamine, it helps to identify viable myocardial tissue.

[Three-dimensional echocardiography: technique, clinical applications, and perspectives]. / Ecocardiografía tridimensional: técnica, aplicaciones clínicas y perspectivas.

OBJECTIVE: Three-dimensional echocardiography represents a new era in the contemporary cardiology, because depicts the cardiac structures in their realistic forms. This information can not be obtained using a two-dimensional perspective. Although two-dimensional (2D) and M-mode echocardiography has greatly enhanced the ability to visualize the functioning heart for more than 30 years, 3D interpretative mental skills are necessary to compile the 2D slices of the complex 3D anatomy, particularly in congenital heart disease. CONCLUSIONS: At present, its additional morphological and functional information in surgical decision-making and the increasing number of clinical questions than can be answered justify the clinical use of this technique. In the future it will the study of "virtual" pathologic anatomy.

The effect of kidney transplant on cardiac function: an echocardiographic perspective.

Kidney transplant (KT) resolves many of the cardiac abnormalities associated with chronic kidney failure (CKF). This study analyzed cardiac alterations of kidney failure and their modification with transplant. Thirteen patients in CKF underwent conventional echocardiograms, dobutamine stress echocardiograms, and injection of contrast to examine perfusion before KT and 3 months after transplant. Nine patients had evidence of left ventricular hypertrophy and six had evidence of diastolic dysfunction. Wall thickness, left ventricular mass, and mass index diminished after KT; only two patients continued to manifest hypertrophy. Left ventricular systolic diameters and volumes diminished at 3 months, and diastolic diameters after 4 months. Left ventricular fractional shortening and ejection fraction increased 3 months after transplant. At the end of the study, only two patients continued to show diastolic dysfunction. Dobutamine echocardiograms showed no segmental wall-movement abnormalities. Myocardial perfusion was normal before and after transplant. The results suggest that KT diminishes hypertrophy and improves left ventricular systolic and diastolic function. Echocardiography provides valuable information for detection and follow-up of cardiac abnormalities in patients with kidney disease. Evaluation of segmental wall movement and myocardial perfusion aid in demonstrating that our studied patients with CKF had no indirect signs of coronary artery disease.

Echocardiographic study of patients with congenital heart disease and infective endocarditis.

BACKGROUND: Infective endocarditis (IE) occurs with significant frequency in patients with congenital heart disease. The complications leading to increased morbidity and mortality may be detected by echocardiographic examination. This study was undertaken in order to identify echocardiographic findings that influence the outcome of patients with congenital heart disease and IE. METHODS: Twenty-five patients with an average age of 28 years were selected and divided into two groups according to evolution. Group I included patients who survived the infectious process, while Group II included patients who died during hospitalization or after release. RESULTS: Aortic valve disease was the most frequent anomaly. The clinical finding of most relevance for evolution during hospitalization was heart failure. Acute kidney failure and multiple organ failure from sepsis were the most common complications in patients who died. Echocardiograms established the diagnosis in all cases. Transesophageal studies revealed all periaortic abscesses. CONCLUSIONS: Echocardiography makes it possible to identify and evaluate complications associated with elevated morbidity and mortality in patients with congenital heart disease and IE.

Evaluation of the response to pharmacological stress in chronic aortic regurgitation.

We evaluated the hemodynamic response of patients with chronic aortic regurgitation and decreased ejection fraction (EF), mean value +/- SD (37 +/- 9), to dobutamine stress echocardiography (DSE). Eleven patients were studied with DSE. Nine patients were in New York Heart Association (NYHA) Class II and two in NYHA Class III. Ten patients received medical treatment in the only other periodic evaluation. With DSE in nine patients, a significant decrease in left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD) as well as LV end-diastolic and end-systolic volumes (LVEDV and LVESV) was documented in comparison to resting values. EF and fractional shortening (FS) improved significantly with DSE. Systolic wall stress (SWS) and pulmonary arterial systolic pressure (PASP) did not change. Average follow-up was 6.7 months. Three patients underwent valve replacement with mechanical prostheses. Two of them are in NYHA Class I and the other died of LV failure 3 days after surgery. One patient deteriorated beyond surgical treatment and was in NYHA Class II. The other seven patients remain in NYHA Class II and await valve replacement. In patients with chronic aortic regurgitation and depressed EF, the variables relevant to myocardial reserve appear to be EF, FS, LVEDD, LVESD, LVEDV, and LVESV.

Two- and three-dimensional echocardiography in primary antiphospholipid syndrome: misdiagnosis as rheumatic valve disease.

This is a report of a woman in the fifth decade of life with primary antiphospholipid syndrome and involvement of a heart valve. Diagnosis was reached with echocardiography and serological studies.

[Utility of echo enhancers in the study of pulmonary circulation time]. / Utilidad de los eco realzadores en el estudio del tiempo de circulación pulmonar.

UNLABELLED: Pulmonary circulation time (PCT) varies under different clinical conditions. To evaluate the PCT, the persistence of contrast in both ventricles and the digital arterial saturation of oxygen with peripheral intravenous injection of microbubbles, were examined 14 patients. Groups: I normals, II left ventricular hypertrophy (EF > 50%), III with mitral stenosis and IV in congestive heart failure. In seven patients, isosorbide S/L was administered after the first injection. The transpulmonary transit in beats was 7.3 in normals, and larger in the others. The persistence of echo contrast in right chambers was 31 beats in group I, and larger in the other groups. In left chambers it was 20.6 beats in group I, and larger in others. There were no alterations with regards to peripheral arterial saturation of oxygen. AII patients with isosorbide presented shorter PCT and persistence of contrast in right chambers. CONCLUSIONS: There are differences in PCT among normals, patients with mitral stenosis and those with congestive heart failure. Prolonged persistence contrast in right chambers indicates abnormally slow transpulmonary transit. Patients with congestive heart failure and ventricular damage, have longer persistence of echo contrast. PCT studied with contrast is an easy means of evaluating some aspects of pulmonary circulation.

[Safety and efficiency of Echogen. Transthoracic echocardiography study]. / Seguridad y eficacia de Echogen. Estudio con ecocardiografía transtorácica.

UNLABELLED: This study was performed to determine the safety and efficacy of intravenous dodecafluoropentane emulsion (Echo Gen), to determine the efficacy and duration of contrast agent in left cavities by transthoracic echocardiography and to evaluate the clinical impact of Echogen. Fifteen patients were studied, by transthoracic echocardiography. Duration of contrast intensity of left ventricular cavity opacification and endocardial border definition were studied. The adverse effects were assessed immediately, 24 hours and 7 days after Echogen. Both the vital signs and electrocardiogram did not show any significant changes. Minimal changes in hepatic function in one patient and in renal function in other one were observed. The mean duration of left ventricular opacification was 4 minutes 47 seconds and full or intermediate opacification was more frequently observed after Echogen. Endocardial border delineation was poor in one patient, intermediate in five and excellent in nine. In 86.7% the diagnostic information obtained was sufficiently and allowed other studies. CONCLUSIONS: This study demonstrates that Echogen is effective for Left ventricular cavity opacification, endocardial border definition and assessment of left ventricular volume and ejection fraction 2) The obtained information with the use of Echogen allowed other studies. 3) The intravenous administration of Echogen is safe in doses of 0.05 ml/Kg.

Two- and three-dimensional echocardiographic unroofed coronary sinus.

We present the 2-dimensional findings and 3-dimensional reconstruction of images from an 18-year-old patient with unroofed coronary sinus, persistent left superior vena cava, a common atrium with levoisomerism, ventricular septal defect, and double-outlet right ventricle. The left superior vena cava showed continuity with the floor of the coronary sinus. Diagnosis of the constellation of anomalies established by transesophageal reconstruction clarified the continuity of the coronary sinus with left superior vena cava and atrial wall.

Cor triatriatum dexter: transesophageal echocardiographic diagnosis and 3-dimensional reconstruction.

Cor triatriatum dexter is an unusual cardiac abnormality with division between the sinus and primitive atrial portions of the right atrium. Three-dimensional echocardiography is a novel technique that defines this entity.

Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction.

The echocardiographic findings of an intramyocardial dissecting hematoma that formed after an extensive acute myocardial infarction of the anterior wall of a 42-year- old man are described. Serial transesophageal studies were used to construct 3-dimensional images that clarified the participation of various myocardial layers that surrounded the dissecting hematoma. The patient was successfully treated with intra-aortic balloon counterpulsation and subsequently coronary artery bypass grafting. Intramyocardial dissecting hematoma is a rare complication of acute infarction; differential diagnosis must be made with pseudoaneurysm by establishing integrity of epicardium and with intracavitary thrombosis by identifying the endomyocardial layer surrounding the neoformation and associated wall movement.

Prognostic implications of right atrial ischemic dysfunction in patients with biventricular inferior infarction: transesophageal echocardiographic analysis.

In order to determine the effect of right atrial dysfunction on clinical outcome, six patients with inferior myocardial infarction with extension to right ventricle and right atrium involving only obstructions of the right coronary artery were examined with transesophageal echocardiography (TEE) at the time of the event. Five of the patients were reexamined 15 to 55 months later. Two patients underwent thrombolysis and maintained ratios of right-to-left ventricular diameters of less than 1, as well as normal convexity of the interatrial septum. One patient had spontaneous reperfusion of the right coronary artery, reduction in right ventricular diameter, and normalization of interatrial septum. Another patient underwent delayed angioplasty and manifested a diminished wall movement score (WMS) in the follow-up echocardiogram. One patient died during his first hospitalization with significant right ventricular dilatation, inverted convexity of the interatrial septum, and right atrial thrombosis. The last patient died during follow-up with right ventricular dilatation, increased WMS, right atrial akinesis, and inverted interatrial convexity. Serial TEE examination of patients with infarction of the left ventricular inferior wall is a safe technique for determining the degree of the extension of the ischemic process to the right chambers.

Transesophageal echocardiographic diagnosis of thrombus in accessory lobes of the left atrial appendage.

Fifty-four percent of left atrial appendages have two lobes. The number ranges from one to four lobes. We describe three patients with accessory lobes of the left atrial appendage studied with multiplanar transesophageal echocardiography (TEE). In one patient there was evidence of thrombi in the accessory lobe.

Severe dynamic obstruction of the left ventricular outflow tract induced by dobutamine.

We present the case of a 63-year-old man who developed a subaortic gradient of 182 mmHg during an echocardiographic pharmacological stress study with dobutamine.

Left atrial thrombosis after percutaneous mitral valvuloplasty: resolution with conservative management.

We report the detection of a thrombus 72 hours after mitral valvuloplasty through the use of the technique of Inoue. Images obtained by transesophageal echocardiography revealed its localization on the interatrial septum at the level of the transseptal puncture. Although the patient subsequently underwent surgery for the placement of a prosthetic valve in mitral position due to failure of the valvuloplasty, the thrombus resolved with conservative management.