Ventricular function during liver reperfusion in hepatic transplantation. A transesophageal echocardiographic study.

Postreperfusion syndrome (PRS) is the most dramatic and acute hemodynamic alteration that occurs in OLT. Our aim was to determine heart function by hemodynamic monitoring and transesophageal echocardiography during PRS. We studied 24 nonconsecutive patients allocated to 2 groups: group A (n = 8), patients with PRS, and group B (n = 16), patients without PRS. Usual hemodynamic data were obtained simultaneously with transesophageal echocardiography recording of the left ventricular imaging in 4 different stages: after induction of anesthesia, 5 min before the end of the anhepatic phase, between 2 and 5 min after reperfusion, and 5 min after graft reperfusion. The hemodynamic and echocardiographic findings during reperfusion were (group A vs. group B patients): mean arterial pressure, 50.0 +/- 15.2 vs. 74.7 +/- 13.9 mmHg (P < 0.01); pulmonary capillary wedge pressure, 12.7 +/- 6.1 vs. 13.9 +/- 5.7 mmHg (NS); left ventricular ejection fraction, 79.6 +/- 9.3 vs. 83.4 +/- 9.4% (NS); left ventricular end diastolic volume index, 35.5 +/- 12.7 vs. 54.7 +/- 21.3 ml/m2 (P < 0.05); and stroke volume index, 27.9 +/- 8.9 vs. 45.5 +/- 15.9 ml/m2 (P < 0.01). There was a mild decrease in left ventricular compliance in group A. We found no alteration in left ventricular function that can justify PRS. The hemodynamic changes during PRS seemed to be caused by an insufficient increase in preload after unclamping.

Early and late exercise testing. Usefulness after percutaneous transluminal coronary angioplasty.

Seventy-five patients 36 to 68 years of age were studied after undergoing successful single-vessel percutaneous transluminal coronary angioplasty (PTCA). In all cases exercise tests (ETs) were made prior to the procedure and 2 to 4 days and 6 months thereafter. Angiographic controls were performed on patients with positive ET. Both early and late ET carried out after dilatation lasted significantly longer. Patients were able to tolerate greater work loads and their heart rates and arterial blood pressures also were higher. The ETs conducted prior to PTCA were positive in 62 patients. After dilatation, the early test was positive in 18 and the late test, in 10. Angiographic controls revealed restenosis in 75 percent of patients with single-vessel disease and positive ET. Thus, the results of ETs in patients with single-vessel disease tend to become negative after successful PTCA. Early and late positive ETs are associated with restenosis, while negative ETs indicate a good prognosis.

Orthostatic tremor: successful treatment with phenobarbital.

This article describes two patients with orthostatic tremor. The tremor affected the legs while standing and had a frequency of 14-16 Hz. We remark on the success of therapy with phenobarbital.

Stunned myocardium and cellular damage in patients undergoing valvular cardiac surgery and pretreated with captopril.

BACKGROUND: Following extracorporeal cardiac surgery, transient myocardial dysfunction (stunning) and cellular damage may develop in relation, among other mechanisms, to the production of free radicals (FR) during reperfusion. The purpose of this study is to evaluate whether captopril (CTP), an angiotensin converting enzyme inhibitor with a thiolic group, which has been shown to be useful as an antioxidant agent both in in vitro and in vivo studies, can prevent emergence of those problems when used as pretreatment within 24 hours in patients undergoing valvular cardiac surgery. EXPERIMENTAL DESIGN: prospective and randomized study. Comparison of data pre-ischemic (pre-aortic clamping) and post-reperfusion (post-cardiac rewarming) was performed. Ejection fraction was compared pre-surgery, after surgery and after 3 months. SETTING: cardiology and cardiovascular surgery services in a general hospital. PATIENTS OR PARTICIPANTS: thirty patients who had to undergo valvular replacement surgery were randomly allocated to two similar groups, one group pretreated with captopril (CTP group, n = 15) and the other group without it (CON group, n = 15). Exclusion criteria (left ventricular ejection fraction <40%, evidence of angiographic coronary disease or prior myocardial infarction and peroperative myocardial infarction). INTERVENTION: in CTP group, the dose of captopril administered was 12.5 mg every 8 hours orally, from 24 hours before. MEASURES: using electron microscopy of myocardial biopsies taken prior to aortic clamping and post-reperfusion, a semi-quantitative analysis was performed on the degree of myocytic damage (MD), mitochondrial swelling (MS), sarcoplasmic reticulum swelling (SRS) and content in glycogen granules (GLY). Left ventricular ejection fraction was evaluated isotopically at three timepoints, preoperatively (EF1), at 2-3 days (EF2) and at 3 months (EF3). Also, analytical data were collected from the coronary sinus to determine creatine phosphokinase (CPK) and activity of the angiotensin converting enzyme (ACE). RESULTS: We noted that, in general, cellular damage resulting from valvular surgery is low, the degree of MS and SRS being lower in the CTP group. In the CTP group, however, there is a stunning phenomenon (EF1: 54.9+/-6.9%; EF2: 50.8+/-8.5%; EF3: 57.7+/-7.7%) which does not occur in the CON group (EF1: 58.0+/-8.3%; EF2: 60.8+/-10.9%; EF3: 63.0+/-9.3%). CONCLUSIONS: We conclude that the cellular damage caused during valvular replacement surgery is small, and emphasize that pretreatment with CTP further minimizes both MS and SRS; however, for reasons as yet unknown, CTP pretreatment may induce myocardial stunning, an indication that at these low rates of cellular damage, CTP has no beneficial effect, either because it is ineffective as an antioxidant agent or because FR formation has little repercussion in human beings, pointing out to the likely existence of other mechanisms that may induce an appearance of postsurgical myocardial stunning.

[Lipomatous hypertrophy of the interauricular septum: diagnosis with transesophageal echocardiography and computerized tomography]. / Hipertrofia lipomatosa del tabique interauricular: diagnóstico mediante ecocardiografía transesofágica y tomografía computadorizada.

Transesophageal echocardiographic and computed tomographic imaging in a patient with lipomatous hypertrophy of the interatrial septum and advanced left bundle branch block are presented. Transesophageal echocardiography demonstrated a thickening of the atrial septum sparing the fossa ovalis region. Computed tomographic scan at the level of the interatrial septum showed a mass of fat density, and the HIS bundle electrogram showed an advanced infra-his block after intravenous ajmaline. We stress the utility of transesophageal echocardiography in this disorder, and the possible relationship between lipomatous hypertrophy of the interatrial septum and conduction disturbances.

[Acute myocardial infarction secondary to non-penetrating thoracic trauma]. / Infarto de miocardio agudo secundario a traumatismo torácico no penetrante.

We present a case of acute myocardial infarction located anteriorly in a healthy young man who suffered a blunt chest trauma following a motor vehicle accident, with coronarographic evidence of intimal dissection of the left anterior descending artery and evolution to ventricular aneurysm. We comment on the rare incidence of this entity and the mechanism involved in this case, a coronary contusion with subsequent intimal dissection.

[Tetralogy of Fallot complicated by severe hemoptysis in the adult]. / Tetralogía de Fallot en el adulto complicada con hemoptisis grave. Tratamiento mediante embolización de la arteria tirocervical izquierda.

Fallot tetralogy with pulmonary artery atresia is a special situation in which the patient can survive up to middle-age. In these cases some complications such as hemoptysis can appear with difficult treatment that endangers the life of the patient. When the cause of bleeding is the arteriovenous shunts, which are frequent in the multiple vascular malformations originated in this congenital cardiopathy, the selective embolization of these malformations can be an effective option of treatment.

[Intracoronary stents in small vessels: short- and long-term clinical results]. / Stents intracoronarios en vasos pequeños: resultados clínicos a corto y largo plazo.

OBJECTIVE: To assess the clinical outcome of coronary stenting in small vessels (< 3 mm), using high pressure balloon inflation and antithrombotic therapy. PATIENTS AND METHODS: Vessel size was evaluated as < or >= 3 mm at the time of procedure and measured at a level of maximum diameter. We studied 234 consecutive patients with placement of 300 stents in 279 lesions, comprising 84 stents implanted in 79 lesions located at small vessels (< 3 mm). The standard technique included high pressure balloon inflation (15.8 +/- 2.2 atm) and post-stenting therapy with ticlopidine and aspirin for one month. Mean clinical follow-up was 17.6 +/- 10 months. RESULTS: Procedural success without in-hospital major events was similar between small and large vessels (93.7 in vessels of < 3 mm vs 93.5% in vessels of >= 3 mm; p = NS). Three small vessels presented subacute stent thrombosis, whereas no thrombotic occlusion occurred in large vessels (3.8 vs 0%; p = 0.006). At two years, small vessels had a lower target lesion revascularization free survival (73.6 vs 90.3%; p < 0.001). After adjustment for variables previously described as predictors of stent restenosis, in multivariate analysis, a small vessel of < 3 mm was an independent predictor of target lesion revascularization (p = 0.001). Although patients with stenting in small vessels did not differ significantly in terms of any cause death (4.6 vs 3.8%; p = 0.7) nor acute myocardial infarction (2.9 vs 1.1%; p = 0.3), event-free survival was significantly lower after two years (69.1 vs 86.6%; p < 0.001). CONCLUSIONS: As compared to large vessels, coronary stenting in small vessels was performed with similar rates of initial success, however they had a significantly worse clinical long-term outcome in terms of subacute stent thrombosis and target lesion revascularization at follow-up.

[Subacute thrombosis with antiplatelet treatment in a non-selected population of intracoronary stents: incidence and predictors]. / Trombosis subaguda con tratamiento antiagregante en una población no seleccionada de stents intracoronarios: incidencia y predictores.

INTRODUCTION: After coronary stenting, the incidence of subacute stent thrombosis have been reduced to 0% using aspirin and ticlopidine, in studies with selected populations and intracoronary ultrasounds. OBJECTIVE: To evaluate the incidence and predictors of subacute stent thrombosis in a nonselected population, using antithrombotic therapy. METHODS: We studied 285 stents, consecutively and successfully implanted in 268 lesions of 226 patients. We used high pressure balloon inflation without intracoronary ultrasound. Post-stenting protocol included aspirin and ticlopidine during four weeks with no anticoagulation. We defined subacute stent thrombosis as death, acute myocardial infarction myocardial infarction or angiographic occlusion of stent, with TIMI flow 0-1, after the first 24 hours and during the first month. RESULTS: Four patients presented events (1.7%): Three nonfatal myocardial infarction after discharge, with documented angiographic thrombosis of stent, and one death due to in-hospital myocardial infarction. All three non-fatal AMI, occurred in vessels less than 3 mm (p = 0.07) and in patients taking aspirin without ticlopidine (p < 0.001). After discharge, three (17%) of 18 patients with inadvertent discontinuation of ticlopidine presented subacute stent thrombosis, in contrast to none of 25 patients taking ticlopidine without aspirin. Excluded patients with discontinuation of ticlopidine, the incidence of subacute stent thrombosis was 0.5%. CONCLUSION: After intracoronary stenting in a nonselected population, using antithrombotic treatment with aspirin and ticlopidine, we may expect a rate of subacute stent thrombosis about 1%. Ticlopidine seems to have the main role in preventing subacute stent thrombosis, above all in predisposing circumstances as small vessels.

[Hypertrophic myocardiopathy (I). The clinical and echocardiographic characteristics of a population of 72 patients]. / Miocardiopatía hipertrófica (I). Características clínicas y ecocardiográficas en una población de 72 pacientes.

The results of the echocardiographic evaluation of 72 patients with hypertrophic cardiomyopathy are presented. We have measured left ventricular wall thickness in 8 different segments and classified our patients in 6 types according to the hypertrophy extent. Moreover, we have evaluated by Doppler ultrasound the presence and severity of mitral regurgitation and the left ventricular inflow and outflow. The hypertrophy cardiomyopathy pattern was symmetric in 8 patients, apical in five, and asymmetric in 31. According to Maron classification, asymmetric cardiomyopathy was I type: 4 patients, II type: 16, III type: 11, and IV type: 0 patients. There were left ventricular outflow obstruction (greater than 25 mmHg) in 26 patients (36.1%). This obstruction was more frequent in II and III type hypertrophic cardiomyopathy and we found significative relationship between septal posterior segment hypertrophy and left ventricular outflow obstruction. Ventricular inflow showed bad distensibility pattern in 45 patients (62.5%). Mitral regurgitation was mild, moderate and severe in 25, 15, and 4 patients. Left ventricular outflow obstruction, bad distensibility pattern and mitral regurgitation were independent each other.

[Reperfusion arrhythmias in valvular patients undergoing extracorporeal surgery and pretreated with captopril]. / Arritmias de reperfusión en pacientes valvulares operados con cirugía extracorpórea y pretratados con captopril.

INTRODUCTION AND OBJECTIVES: After the ischemia-reperfusion process in extracorporeal cardiac surgery there are, among several phenomena, some reperfusion arrhythmias which are influenced by a varied series of mechanisms. These arrhythmias have been related to the release of oxygen-derived free radicals during the first moments of reperfusion. Thus, a previous administration of free-radical scavengers might be beneficial, among which captopril has been included with good results in human studies in vitro and in animals in vivo. The aim of this study was to evaluate the influence of pretreatment with captopril on the prevention of reperfusion arrhythmias in patients undergoing valvular cardiac surgery. METHODS: 30 patients were randomly allocated to pretreatment with either captopril (CTP group, n = 15) or without captopril (CON group, n = 15). Exclusion criteria (left ventricular ejection fraction < 40%, evidence of angiographic coronary disease, prior myocardial infarction and preoperatory myocardial infarction). The dose of captopril administered was 12.5 mg every 8 hours orally, from 24 hours before surgery. A Holter register was used to analyze the ventricular arrhythmias (extrasystoles, salvos, tachycardia and fibrillation) during the first hour of reperfusion. The need for cardioversion was examined and the number of shocks needed. These events were related to changes in blood analyses from coronary sinus samples to determine creatine phosphokinase, activity of the angiotensin converting enzyme and cyclic adenosine monophosphate, before aortic clamping and after the heart was rewarmed. RESULTS: No significant differences were found in the number of ventricular arrhythmias. 60% of the patients with captopril and only 40% of the patients without it (non significant) had spontaneous defibrillation without electric shock; in those cases in which it was necessary, the number of shocks was less in the captopril group (p < 0.05). Excepting the significant correlation (p < 0.01) that we have found between ventricular fibrillation and the cyclic adenosine monophosphate increase, there is no significant correlation between the other arrhythmias and the analytical data studied. CONCLUSIONS: These data suggest that captopril, given before cardiac surgery, has little or no protector effect on reperfusion ventricular arrhythmias in extracorporeal cardiac surgery, though in patients treated with captopril there is a greater possibility of spontaneous defibrillation and fewer shocks necessary for defibrillation, without negative effects.

[Isotopic ventriculography in patients with obstructive hypertrophic cardiomyopathy treated with dual chamber stimulation]. / Ventriculografía isotópica en pacientes con miocardiopatía hipertrófica obstructiva tratados con estimulación bicameral.

BACKGROUND: Dual pacing stimulation improves symptoms and reduces intraventricular pressure gradient in obstructive hypertrophic cardiomyopathy. The mechanisms proposed for these effects are a change in ventricular contraction sequence, a paradoxical movement of the interventricular septum and a reduction in ventricular contractility. However, dual chambers pacing stimulation effects on systolic and diastolic function are unknown, and the study of this is the aim of this work. PATIENTS AND METHODS: We performed a radionuclide ventriculography in 10 patients with obstructive hypertrophic cardiomyopathy at 2 days and 1 and 6 months after placing a dual chamber pacemaker. The phase images, ventricular volumes, left ventricular ejection fraction and segmentary contractility were evaluated. Diastolic maximum peak-filling-rate and time to-peak-filling-rate were also studied. RESULTS: In DDD pacing stimulation, parametric phase images show a reversal up-down contraction sequence starting from the apical segment. At 6 months radionuclide ventriculography, a reduction in ejection fraction was found (60.9 +/- 12 vs 73.4 +/- 9.1; p < 0.05) which was attributed to apical, apical-septum and mainly basal-septum segmentary contraction decrease. A paradoxical mid-systolic septum movement was also found during DDD stimulation. No differences on diastolic parameters were noted. CONCLUSION: During dual chamber stimulation, a reversal ventricular contraction sequence, a paradoxical septum movement, hypokinesis of the septal ventricular segments and a reduction on left ventricular ejection fraction was observed.

[Follow-up of left ventricular systolic function in the first year following previous infarction]. / Seguimiento de la función sistólica ventricular izquierda en el primer año tras infarto anterior.

OBJECTIVES: To follow the left ventricular systolic function changes as assessed by global and regional ejection fraction during the first year of evolution after anterior myocardial infarction, as well as to analyse how the most relevant clinical and angio-graphic parameters influence them. MATERIALS AND METHODS: Sixty-six consecutive patients with a first infarction of anterior location, completed 1 year of follow-up with radionuclide ventriculography, T1-SPECT after exercise or dypiridamole and cardiac catheterization before discharge; radionuclide ventriculography was repeated 6 and 12 months later. Twenty-five patients underwent revascularization procedures at the time of predischarge, 16 using successful percutaneous angioplasty of the left anterior descending artery and 9 using aorto-coronary graft surgery. Dilated patients were controlled, from an angiographic point, of view 6 months after PTCA. RESULTS: Predischarge global EF (42.9 +/- 12.6) increased significantly between the 6-month (46.9 +/- 12.8; p < 0.001) and 12-month (47.6 +/- 12; p < 0.001) studies. Differences in these two last studies were minor and had no statistical significance. A significant increase was present in revascularized or medically treated patients; i.e. those who underwent thrombolytic therapy or conventional treatment at admittance as well as mono or multivessel disease patients. No significant differences were detected in the mean ejection fraction in patients without residual stenosis in the infarct-related artery (48.1 +/- 13.3 vs 50 +/- 12.6; NS) or those presenting a pre-discharge ejection fraction > or = 45% (53.5 +/- 7.5 vs 55.1 +/- 3.3; NS). Among different variables tested, predischarge global ejection fraction (negative coefficient) and, to a lesser extent, percutaneous angioplasty were independent predictors of a significant increase of ejection fraction during follow-up. Changes from predischarge to 12 month study were significant in the regional ejection fraction in the anteroseptal (33.1 +/- 14.7 vs 40.1 +/- 13.3; p < 0.001), inferoseptal (34.6 +/- 15.8 vs 42 +/- 16.9; p < 0.001), apical (46.3 +/- 19.1 vs 50.8 +/- 19.7; p < 0.01), antero-medial (50.6 +/- 22.4 vs 56.6 +/- 24.3; p < 0.01) and anteroapical (51.6 +/- 23.5 vs 58 +/- 27.5; p < 0.01) segments. In the anterobasal segment, regional ejection fraction only showed a statistical tendency to increase during follow-up and changes in inferior and lateral segments, distal to the infarcted area, were minor and without statistical significance. The most distinct infarct-related segments, antero- and inferoseptal, showed significant increases in the main group of patients, revascularized or nonrevascularized, undergoing thrombolitic or conventional therapy, with single or multivessel disease. Only patients without residual stenosis of the infarct-related artery (the left descending anterior) disclosed negligible or negative changes without statistical significance. Percutaneously dilated patients showed the highest increase of the infarct-related segments regional ejection fraction. In multivessel disease, the infarct-related segments regional ejection fraction did not increase significantly in surgically treated patients, conversely to those who underwent medical therapy. CONCLUSIONS: Global and regional ejection fraction of the infarcted area increased significantly during the first year after anterior myocardial infarction, mainly prior to six months patients with significant residual stenosis of the artery related to the infarct. Recovery is present both in patients who underwent thrombolysis or conventional treatment at admittance and revascularization or medical treatment before discharge and is inversely correlated to the predischarge global ejection fraction value. This evolution suggests that a significant amount of stunned myocardium is still present before discharge.

[Is the predischarge exercise test valid in patients younger than 40 years old after myocardial infarct for determination of multivascular disease?]. / Es válida la prueba de esfuerzo precoz en pacientes jóvenes menores de 40 años tras infarto de miocardio para la determinación de enfermedad multivaso?

BACKGROUND AND OBJECTIVES: Conventional exercise testing before hospital discharge is the most useful procedure in order to estimate postinfarction prognosis and in detecting multivessel coronary disease which is associated with a poor long-term prognosis. There are no bibliographic reports about it in younger myocardial infarction survivors. The aim of the study was to evaluate sensitivity, specificity and predictive value of symptoms limited maximal exercise testing for multivessel disease diagnosis in young patients after myocardial infarction. METHODS: Myocardial infarction survivors until the age of 40 performed symptoms limited maximal exercise testing and had a coronary arteriography before hospital discharge. RESULTS: A total of 100 consecutive patients were included, although in only 83 of them exercise tests and coronariographic studies were done. In this group, multivessel disease was confirmed in 27 patients (15 with positive tests and 12 with normal exercise testing). In the remaining 56 young adults without multivessel involvement, positive tests were only observed in 15 patients and normal tests in 45. Thus, a sensitivity of 56%, specificity of 73%, positive predictive value of 50% and negative predictive value of 77% were found. When patients showed high risk exercise test criteria, the exercise test positive predictive value increased to 80%. CONCLUSIONS: Due to the lower sensitivity of this test in young myocardial infarction survivors for detecting multivessel artery disease, we remark on the need for predischarge complementary tests such as isotopic, stress echocardiography or coronariography testing.

[Detection of residual ischemia after acute anterior myocardial infarction using Thallium-201 SPECT]. / Detección de isquemia residual tras infarto agudo de miocardio de localización anterior mediante SPECT con talio-201.

OBJECTIVES: To assess the utility of single photon emission computed tomography (SPECT) with Thallium-201 after anterior myocardial infarction at predischarge time in the detection of; a) the prevalence of isotopic redistribution in the infarct area or at a distance; b) the correlation between peri-infarction ischemia and the angiographic state of the infarct-related artery, and c) the correlation between ischemia at a distance and the presence of multivessel disease. MATERIAL AND METHOD: Seventy-three survivors of an uncomplicated anterior myocardial infarction, 67 men and 7 women, with a mean age of 56 +/- 9 years (34-70 range), underwent T1-SPECT after stress test (62 exercise test and 11 pharmacological Dipyridamole test) as well as coronarographic studies before discharge. Peri-infarction ischemia was defined as redistribution presence in the distribution territory of the left anterior descending artery (LAD) and was assessed in a semi-quantitative way scoring both stress and rest images that allowed the calculation of a redistribution index R (Stress Score-Rest Score/Stress Score). Ischemia at a distance was defined as redistribution presence in the territories of circumflex and right coronary arteries as assessed both by visual analysis (VA) and bull's eye polar maps (BE) or by washout imaging (WO). RESULTS: Peri-infarction ischemia (R > 0) was found in 48 (65.7%) patients; 43 with and 5 without significant residual lesions in the LAD and the absence of peri-infarction ischemia (R = 0) was found in 25 (34.3%) patients, 19 with and 6 without significant residual lesions in the LAD. Sensitivity and specificity for multivessel disease detection by ischemia at a distance was 64% and 85% respectively, for VA; 60% and 77% for BE; and 95% and 65% for WO. Combinations of different analytical methods (multiparametric approach) showed a decrease in sensitivity but improved specificity and positive predictive value: 60%, 90% and 75%, respectively, for BE & WO; 44%, 90% and 69% for VA & BE and 60%, 92% and 79% for VA & WO. CONCLUSIONS: TI-SPECT imaging is a useful diagnostic method to detect both peri-infarction ischemia and ischemia at a distance at predischarge time following anterior myocardial infarction. Redistribution presence in the non infarct-area shows a fair sensitivity and a high positive predictive value to detect residual multivessel disease.