[Direct stent implantation in acute myocardial infarction. The DISCO 3 study]. / Implante directo del stent en el infarto agudo de miocardio. Estudio DISCO 3.

INTRODUCTION AND OBJECTIVES: An association has been reported between direct stenting in primary angioplasty and low incidences of the no-reflow phenomenon and distal embolization. The aims of this study were to determine the proportion of patients who can be treated by direct stent implantation and to identify factors that establish when the technique should be used in acute myocardial infarction in clinical practice. PATIENTS AND METHOD: This prospective descriptive and multicenter study (DISCO 3) included 189 patients. Angiographic reperfusion parameters were recorded and resolution of the ST-segment elevation was monitored. Adverse clinical events, such as death, non-fatal reinfarction and repeat revascularization of the culprit vessel, were recorded at discharge, and after one and six months. RESULTS: Direct stenting was performed in 56% of patients, and stenting after predilatation in 44%. The main predictors of direct stenting were short postinfarction delay, non-zero initial TIMI flow, and preinfarction angina. The most common reasons for balloon predilatation were TIMI flow zero on traversing the lesion with a guidewire (92%), involvement of a major bifurcation or tortuous vessel, and severe calcification. Indices of myocardial reperfusion were better with direct stenting: TIMI myocardial perfusion grade 2-3 flow was present in 84% vs 69% (P=.005), and > 70% ST-segment resolution occurred in 66% vs 42% (P=.003). No difference in adverse clinical events was found. CONCLUSIONS: Direct stenting is feasible for treating acute myocardial infarction in more than half of patients. The lesions should not be severely calcified nor involve tortuous vessels, and there should be sufficient flow following passage of a guidewire to define the lesion's characteristics.

Implante directo del stent en el infarto agudo de miocardio. Estudio DISCO 3 / Direct stent implantation in acute myocardial infarction. The DISCO 3 study

Introducción y objetivos. El implante directo del stent en la angioplastia primaria se ha asociado con una menor incidencia de no reflujo y embolización distal. El objetivo de este estudio fue evaluar la proporción de pacientes que puede ser tratada y los factores que determinan la implantación directa del stent en el infarto agudo de miocardio en la práctica habitual. Pacientes y método. Se incluyó a 189 pacientes en este estudio descriptivo, prospectivo y multicéntrico (DISCO 3). Se analizaron los resultados angiográficos y de resolución de la elevación del segmento ST. Se registraron los acontecimientos clínicos (muerte, reinfarto no mortal y nueva revascularización del vaso causante) en el momento del alta, al mes y a los 6 meses. Resultados. Se trató con stent directo (SD) al 56% de los pacientes y con stent tras predilatación (SP) al 44%. Los mejores predictores de SD fueron: menor tiempo de evolución del infarto, flujo TIMI inicial distinto de 0 y presencia de angina preinfarto. Los motivos para la predilatación fueron: presencia de un flujo TIMI 0 tras cruzar la lesión (92%), bifurcación mayor, calcificación y tortuosidad severas. Los índices de reperfusión miocárdica fueron mejores en el grupo de SD, con un grado de perfusión miocárdica TIMI 2-3 (el 84 frente al 69%; p = 0,005) y una resolución del segmento ST > 70% (el 66 frente al 42%; p = 0,003). No hubo diferencias significativas en la presencia de eventos clínicos adversos en el seguimiento. Conclusiones. El uso del SD en el tratamiento del infarto agudo de miocardio de menos de 12 h de evolución es factible en más de la mitad de los casos, cuando las lesiones no presentan calcificación y/o tortuosidad severas, y cuando se consigue, tras el paso de la guía, un flujo mínimo que permita definir las características de la lesión

Introduction and objectives. An association has been reported between direct stenting in primary angioplasty and low incidences of the no-reflow phenomenon and distal embolization. The aims of this study were to determine the proportion of patients who can be treated by direct stent implantation and to identify factors that establish when the technique should be used in acute myocardial infarction in clinical practice. Patients and method. This prospective descriptive and multicenter study (DISCO 3) included 189 patients. Angiographic reperfusion parameters were recorded and resolution of the ST-segment elevation was monitored. Adverse clinical events, such as death, non-fatal reinfarction and repeat revascularization of the culprit vessel, were recorded at discharge, and after one and six months. Results. Direct stenting was performed in 56% of patients, and stenting after predilatation in 44%. The main predictors of direct stenting were short postinfarction delay, non-zero initial TIMI flow, and preinfarction angina. The most common reasons for balloon predilatation were TIMI flow zero on traversing the lesion with a guidewire (92%), involvement of a major bifurcation or tortuous vessel, and severe calcification. Indices of myocardial reperfusion were better with direct stenting: TIMI myocardial perfusion grade 2-3 flow was present in 84% vs 69% (P=.005), and > 70% ST-segment resolution occurred in 66% vs 42% (P=.003). No difference in adverse clinical events was found. Conclusions. Direct stenting is feasible for treating acute myocardial infarction in more than half of patients. The lesions should not be severely calcified nor involve tortuous vessels, and there should be sufficient flow following passage of a guidewire to define the lesion's characteristics

[Percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa]. / Cierre percutáneo de seudoaneurisma de la fibrosa mitroaórtica.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is an uncommon event, which is usually secondary to endocarditis of the aortic valve. Its clinical evolution is variable and potentially serious complications can occur. Therefore, surgical treatment is usually recommended. To the best of our knowledge, this is the first description of percutaneous treatment of this disease.

Cierre percutáneo de seudoaneurisma de la fibrosa mitroaórtica / Percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa

El seudoaneurisma de la fibrosa mitroaórtica es una entidad infrecuente, generalmente secundaria a una endocarditis sobre la válvula aórtica. Su curso clínico es variable y puede ocasionar complicaciones graves, por lo que habitualmente se recomienda su tratamiento quirúrgico. Presentamos la primera descripción, según la información de que disponemos, de tratamiento percutáneo de esta enfermedad

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is an uncommon event, which is usually secondary to endocarditis of the aortic valve. Its clinical evolution is variable and potentially serious complications can occur. Therefore, surgical treatment is usually recommended. To the best of our knowledge, this is the first description of percutaneous treatment of this disease

[Aortic root homograft in the surgical treatment of aortic valve disease with dilated ascending aorta]. / Homoinjerto de raíz aórtica para el tratamiento quirúrgico de las afecciones de la válvula aórtica con aorta ascendente dilatada.

INTRODUCTION AND OBJECTIVES: Patients with aortic valve disease and a dilated ascending aorta are usually treated with a composite graft comprising a valve and conduit. We review here the results of treatment with an aortic root homograft as a valid alternative. PATIENTS AND METHOD: Twenty-two consecutive patients with a mean age of 64.8 (8.8) years were studied. Mean ascending aorta dilation was 54.55 mm, aortic valve insufficiency was present in 16 patients, and a combined lesion was present in 6. In all cases a cryopreserved aortic root homograft was used to replace the aortic valve and ascending aorta. In 9 cases a Dacron conduit was used beyond the sinotubular junction to restore continuity between the homograft and the native aorta. RESULTS: All patients survived surgery. One patient had postoperative systemic inflammatory response syndrome and one patient was re-explored for excessive bleeding. Mean duration of follow-up was 12.1 months (range 2-36 months). No patient was given anticoagulants, and one had an early transient cerebrovascular accident followed by complete recovery. At one month postsurgery the left ventricular systolic (P<.001) and diastolic (P<.009) diameters had decreased significantly on echocardiography, and these decreases persisted throughout follow-up. The caliber of the ascending aorta was normal in all patients (< or =30 mm) except one. CONCLUSIONS: Aortic root homografts are a valid alternative in the treatment of aortic valve disease with ascending aorta dilation. The main advantages of this therapy are that permanent anticoagulation is not needed, and that left ventricular dimensions recover rapidly.

[Myocardial infarction and 5,10-methylenetetrahydro-folate reductase mutation]. / Infarto de miocardio y mutación de l enzima 5, 10-metilentetrahidrofolato reductasa.

A 40-year-old woman with previous venous thrombosis in the lower limbs had recurrent myocardial infarction in the early puerperium. The only documented risk factor was an elevated level of plasma homocysteine, associated to a heterozygotic anomaly in the enzyme responsible for its metabolism, 5,10-methylenetetrahydrofolate reductase. The case and approaches to treatment are discussed.

Cierre percutáneo de la comunicación interauricular: resultados a medio plazo de esta nueva opción terapéutica / Percutaneous Closure of Atrial Septal Defects: Midterm Results of a New Therapeutic Strategy

Objetivo. Evaluar los resultados a medio plazo del cierre percutáneo de la comunicación interauricular mediante dos nuevos dispositivos. Pacientes y métodos. Bajo anestesia general se procedió por vía anterógrada al cierre percutáneo de la comunicación interauricular tipo II de nueve niños. La edad fue de 5,1 ñ 1,9 años y el peso 19,7 ñ 7 kg. El procedimiento fue monitorizado mediante ecocardiografía transesofágica. Los dispositivos utilizados fueron el DAS Angel Wings y el Amplatzer. Resultados. Los resultados hemodinámicos fueron: presión arteria pulmonar 12,7 ñ 2 mmHg, resistencias pulmonares 1,5 ñ 0,5 U/m2 y Qp/Qs 2,3 ñ 1. El diámetro del defecto por ecocardiografía transesofágica fue de 11,4 ñ 2 mm y por oclusión con balón de 12,3 ñ 2,6 mm. Se emplearon 13 dispositivos, nueve Amplatzer y cuatro dispositivos de DAS-Angel Wings. Cuatro dispositivos Amplatzer fueron retirados sin problemas a través de su introductor, dos por no estabilizarse en el tabique al ser demasiado pequeños y otros dos por apertura defectuosa en la aurícula izquierda. En los nueve pacientes el dispositivo quedó correctamente implantado y en la angiografía al finalizar el procedimiento existía un mínimo cortocircuito en cinco. La ecocardiografía transtorácica con Doppler color realizada a las 24 h demostró la ausencia de cortocircuito en todos.Los niños fueron dados de alta a las 38 ñ 12 h y en el seguimiento de 9,6 ñ 2,2 meses no se han producido complicaciones, fracturas de la estructura, ni se han demostrado co tocircuitos residuales. Conclusión. Mediante cierre percutáneo se consigue una elevada tasa de cierre sin cortocircuito residual cuando se realiza una adecuada selección de los pacientes (AU)