Utility of real-time three-dimensional transesophageal echocardiography in evaluating the success of percutaneous transcatheter closure of mitral paravalvular leaks.

BACKGROUND: The percutaneous closure of mitral paravalvular leaks has been reported in patients who are poor operative candidates. Unsuccessful percutaneous closure of leaks may be related to morphologic characteristics of the defects. METHODS: Ten patients were selected from a database for mitral dehiscence closure, in whom two-dimensional transesophageal echocardiography revealed inadequate leak closure. Another 4 patients with optimal results were also selected. Real-time three-dimensional transesophageal echocardiography (3DTEE) was performed in all of them. RESULTS: Real-time 3DTEE enabled the determination of the locations and number of the leaks, as well as their shapes, lengths, widths, areas, and extent. We were also able to observe the position of the device (or devices) implanted during percutaneous closure. CONCLUSION: According to this preliminary study, 3DTEE can improve understanding of the causes underlying failure of these techniques to reduce regurgitation secondary to a defect. This could improve patient selection and procedure results, but further studies are needed.

[Influence of gender on the etiology of mitral regurgitation]. / Influencia del sexo en la etiología de la insuficiencia mitral.

Our aim was to investigate the prevalence of the different causes of severe mitral regurgitation and the influence of gender on that prevalence. We performed a prospective study of 272 consecutive patients with severe mitral regurgitation that had been detected echocardiographically. Their mean age was 70.2 (13.8) years, and 143 were women (52.6%). Atrial fibrillation was present in 52.9%, 72.7% presented with heart failure, and 21.0% with previous myocardial infarction. The most common etiological factor was rheumatic disease (in 26.5%), with the etiology being unclear in 32 patients (11.8%). Rheumatic disease was more frequent in women, at 35.7%, than in men, at 16.3%, whereas other etiologies were less frequent in women (P< .001). In all age groups, a rheumatic etiology was more frequent in women. Rheumatic heart disease remains the main cause of severe mitral regurgitation observed in women referred to hospitals similar to ours.

Influencia del sexo en la etiología de la insuficiencia mitral / Influence of gender on the etiology of mitral regurgitation

Para valorar la frecuencia actual de las distintas causas de insuficiencia mitral severa y la influencia del sexo en la etiología, realizamos un registro prospectivo de 272 pacientes consecutivos con insuficiencia mitral severa en el ecocardiograma. La edad media fue de 70,2 ± 13,8, con 143 mujeres (52,6%). El 52,9% presentaba fibrilación auricular, el 72,7% insuficiencia cardiaca y el 21,0%, infarto de miocardio previo. La etiología más frecuente fue la reumática (26,5%) y en 32 pacientes (11,8%) no se encontró una clara etiología de la regurgitación mitral. La enfermedad reumática fue más frecuente en mujeres (35,7%) que en varones (16,3%), mientras que otras etiologías fueron menos frecuentes en las mujeres (p < 0,001). Para todos los grupos de edad, la etiología reumática era más frecuente en mujeres. La enfermedad reumática sigue siendo la causa principal de la insuficiencia mitral grave en las mujeres remitidas a un hospital de las características del nuestro

Our aim was to investigate the prevalence of the different causes of severe mitral regurgitation and the influence of gender on that prevalence. We performed a prospective study of 272 consecutive patients with severe mitral regurgitation that had been detected echocardiographically. Their mean age was 70.2 (13.8) years, and 143 were women (52.6%). Atrial fibrillation was present in 52.9%, 72.7% presented with heart failure, and 21.0% with previous myocardial infarction. The most common etiological factor was rheumatic disease (in 26.5%), with the etiology being unclear in 32 patients (11.8%). Rheumatic disease was more frequent in women, at 35.7%, than in men, at 16.3%, whereas other etiologies were less frequent in women (P<.001). In all age groups, a rheumatic etiology was more frequent in women. Rheumatic heart disease remains the main cause of severe mitral regurgitation observed in women referred to hospitals similar to ours

Complicaciones cardiacas en la cirugía no cardiaca: una primera aproximación a una población general de bajo riesgo en nuestro entorno / Cardiac complications of non-cardiac surgery: initial approaches in the general low-risk population in Spain

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Heart failure in the elderly: age-related differences in clinical profile and mortality.

BACKGROUND: Age influence in the prognosis in unselected patients with heart failure has not been widely studied. AIMS: To evaluate possible differences in clinical profile and outcome of patients hospitalized with HF according to age. METHODS AND RESULTS: During 1996, a total of 1065 hospital in-patients had confirmed heart failure, with follow-up data through 2002. Patients were separated in two groups < or = 75 and > 75 years of age. Older patients were less frequently men (32 vs. 52%) and had a higher prevalence of previous stroke (14 vs. 10%). Echocardiography was performed less frequently in older patients (55% vs. 78%) and normal systolic function (55 vs. 40%), and aortic stenosis (12 vs. 7%) were more prevalent. They received less anticoagulants (11 vs. 43%) and beta-blockers (2 vs. 7%), while the opposite happened with aspirin (32 vs. 23%) and diuretics (88 vs. 80%). During follow-up, 507 patients died: 55.9% vs. 38.5%. Being > 75 years of age was the strongest predictor of mortality HR: 1.7, CI 95% 1.5-2.1, P < 0.0001. CONCLUSION: Patients with 76 or more years admitted with HF have a different clinical profile. Echocardiography, oral anticoagulation and beta-blockers were underused in these patients. Age was the strongest predictor of long-term mortality.

Pharmacological treatment in patients with heart failure: patients knowledge and occurrence of polypharmacy, alternative medicine and immunizations.

AIMS: To evaluate in patients with heart failure (HF) due to systolic dysfunction the occurrence of polypharmacy, alternative medicine, immunization against influenza, and patients' knowledge about their medication. METHODS AND RESULTS: Sixty-five patients, 49 men, mean age 60.5+/-12.0 years answered a confidential questionnaire during 2002. Polypharmacy was frequent, 48 (74%) were taking six or more pills per day and 18 (28%) 11 or more. Fifteen patients (23%) used over-the-counter analgesics. Eight patients (12%) used alternative medicine [five women (31%) vs. three men (6%), P=0.02]. Forty-four patients (68%) received immunization against influenza (18 patients <65 years (54%) vs. 25 patients > or =65 years (79%), P=0.03). Half the patients knew that beta-blockers and vasodilators decreased blood pressure, 31 patients receiving diuretics (88%) knew that this drugs help to eliminate liquids, 12 patients (38%) recognized this effect with low dose spironolactone and 23% or less with other drugs. Only 12 patients (42%) treated with acenocoumarol and 13 of those treated with aspirin (32%) recognized the action of these drugs. CONCLUSION: Patients with HF and systolic dysfunction have a poor knowledge about the medication they receive. Polypharmacy, over-the-counter, homeopathic and alternative medicine use is frequent whereas the rate of immunization against influenza is low.

Systolic dysfunction is a predictor of long term mortality in men but not in women with heart failure.

AIMS: To evaluate possible gender differences in clinical profile and outcome of patients hospitalised with heart failure. METHODS AND RESULTS: During 1996 a total of 1065 hospital in-patients had confirmed heart failure, with follow-up data through 2002. Women (58%) were significantly older, had higher prevalence of hypertension and diabetes, and lower prevalence of ischaemic heart disease, chronic pulmonary disease and alcoholism. The proportion of patients with normal left ventricular ejection fraction (LVEF) increased with age, but in all age groups women had normal LVEF more frequently than men. Echocardiography was performed less frequently in females: 62% vs. 71% in men, P<0.01, and this finding was consistent in all age groups. During follow-up (median 19 months) 507 patients died (216 men [48.8%] and 291 women [46.8%]). Gender was not a predictor of survival when LVEF was included in the model (RH Male Gender 0.8, 95% CI 0.6 to 1.1, P=0.2). There was a significant interaction gender-LVEF (P=0.048): survival was similar in both genders with LVEF >0.3 but women with LVEF 0.3 while men with severely depressed LVEF have a worse prognosis.

[Risk stratification using combined ECG, clinical, and biochemical assessment in patients with chest pain without ST-segment elevation. How long should we wait? ]. / Estratificación de riesgo en pacientes con dolor torácico sin ascenso persistente del segmento ST basado en variables clínicas, ECG y bioquímicas. ¿Cuánto tiempo debemos esperar?

INTRODUCTION: We use clinical, ECG, and biochemical data to stratify risk in patients with chest pain without ST segment elevation. However, the prognostic performance of these studies in relation to time from onset of symptoms is unknown. PATIENTS AND METHOD: In a single-center, prospective study, 321 consecutive patients who had been admitted in the emergency room with a suspected acute coronary syndrome without ST segment elevation were included in the study. Blood samples were collected for CK, CK-MB mass, myoglobin, and cardiac troponin T analysis 6, 12 and 18 hours after the onset of pain and other clinical and ECG data were recorded. Univariate and multivariate analysis was used to identify independent prognostic predictors 6 and 12 hours after the onset of chest pain. RESULTS: Five variables were independent predictors of the recurrence of ischemia. The model correctly classified 82% of the patients. Age, history of coronary artery disease, prolonged chest pain at rest in the preceding 15 days, pain, ST-segment changes with pain, and cardiac troponin T in excess of 0.1 ng/m 12 hours after the onset of chest pain were identified by logistic regression. A similar model was analyzed at 6 hours, after changing the cutoff point for cardiac troponin T. Cardiac troponin T was considered positive with values of 0.04 ng/ml 6 hours after the onset of chest pain. CONCLUSIONS: More than 80% of the patients admitted to the emergency room with chest pain without ST segment elevation can be correctly classified for new ischemic recurrences using clinical, ECG, and biochemical parameters 6 hours after the onset of pain.

Estratificación de riesgo en pacientes con dolor torácico sin ascenso persistente del segmento ST basado en variables clínicas, ECG y bioquímicas. ¿Cuánto tiempo debemos esperar? / Risk stratification using combined ECG, clinical, and biochemical assessment in patients with chest pain without ST-Segment elevation. How long should we wait?

Introducción. Utilizamos datos clínicos, ECG y bioquímicos en la estratificación pronóstica inicial de los pacientes con dolor torácico sin ascenso persistente del segmento ST. Su rendimiento pronóstico global, basado en el tiempo desde el inicio de los síntomas, no ha sido estudiado .Pacientes y método. Estudio unicéntrico y prospectivo de 321 pacientes consecutivos que acudieron a urgencias con sospecha de síndrome coronario agudo sin ascenso persistente del segmento ST y menos de 12 h de evolución. Se determinaron la creatincinasa (CK), la CKMB masa, la mioglobina y la troponina T cardíaca a las 6, 12 y 18 h desde el inicio del cuadro. Analizamos de manera uni y multivariada las variables clínicas, ECG y bioquímicas para identificar predictores pronósticos independientes a las 6 y 12 h, valorando el rendimiento pronóstico global. Resultados. En el análisis de regresión logística, 5 variables obtenidas resultaron predictoras independientes para nuevos acontecimientos cardiovasculares y permitieron clasificar correctamente al 82 por ciento de los pacientes: edad, cardiopatía isquémica previa, dolor prolongado en los 15 días previos, dolor y cambios del segmento ST con dolor y troponina T superior a 0,1 ng/ml a las 12 h del inicio del dolor. La troponina T, considerada positiva con valores superiores a 0,04 ng/ml a las 6 h, permite un modelo a las 6 h similar al de las 12 h. Conclusiones. Es posible identificar correctamente la evolución clínica de más del 80 por ciento de los pacientes que ingresan con dolor torácico sin ascenso del segmento ST con variables clínicas, ECG y bioquímicas en el plazo de 6 h desde el inicio del cuadro (AU)

Annual rates of admission and seasonal variations in hospitalizations for heart failure.

AIMS: To investigate the annual hospitalization rate and seasonal variation in confirmed heart failure (HF) admissions. METHODS AND RESULTS: Records from all admissions to one hospital during 1 year with a HF diagnostic code were reviewed. From 1953 admissions, 595 were excluded because they did not fulfill the diagnostic criteria. A total of 1069 patients had 1358 admissions with confirmed HF. Mean age was 74.8 +/- 11.5 years, 42% were males. The admission data were matched with data from the municipal census with 537,666 people aged > or = 15 years. There were 2.5 admissions per 1000 for the adult population and 26.5/1000 in those aged > or = 80 years. There were 444 males and 625 females, giving a higher rate of admission for female patients 2.2/1000 vs. 1.7/1000 (P < 0.0001), although age adjusted rates in females were higher only for > or = 80 years. Echocardiogram was performed in 706 patients (66%), 325 (46%) had a normal ejection fraction. This proportion increased in females--64% vs. 29% males--and in older patients--55% in > or = 75 vs. 39% in < 75 years. Mortality during the first admission of 1996 was 8.3%. There was a seasonal variation in HF hospitalizations (P < 0.0001) peaking at 25% above average in January and dipping to 33% below average in August. CONCLUSION: The rate of HF admissions was 2.5/1000 with an elderly preponderance and a higher rate of admission in males < 80 years and in females > or = 80 years. A seasonal variation ranging from 25% above average in January to 33% below average in August was observed.

[Utility of the serum biochemical markers CPK, CPK MB mass, myoglobin, and cardiac troponin T in a chest pain unit. Which marker determinations should be requested and when?]. / Utilidad clínica de los distintos marcadores biológicos CPK, CPK MB masa, mioglobina y troponina T en una unidad de dolor torácico. Cuándo, cuáles y cómo pedirlos?

BACKGROUND: The prognostic value of biochemical markers in relation to time since onset of chest pain was evaluated in an emergency room with a chest pain unit. METHODS: In a single-center, prospective study we included 321 consecutive patients admitted to the emergency room with suspected unstable angina IIIB and an evolution of less than 12 hours. Blood samples were collected for CPK, CPK MB mass, myoglobin, and cardiac troponin T assays 6, 12, and 18 h after the onset of pain. ROC curve analysis was carried out to compare biochemical markers in terms of cutoff values and time since onset of pain. We determined the relation between prognosis and biochemical markers before and after adjustment for baseline characteristics. RESULTS: CPK mass and myoglobin showed the maximum sensitivity and specificity for new ischemic recurrences 6 hours after the onset of chest pain with laboratory cutoff values. We had to wait 12 h after the onset of pain for troponin T to be useful using the laboratory cutoff value (0.1 ng/ml). A single determination 6 hours after onset of chest pain of cardiac troponin T above 0.04 ng/ml was the most sensitive and specific marker for new ischemic recurrences. CONCLUSIONS: A single blood determination of cardiac troponin T 6 hours after the onset of chest pain complete the prognostic stratification in combination with clinical and ECG variables. The best cutoff point of cardiac troponin T, based on univariate and multivariate analysis, was 0.04 ng/ml 6 h after the onset of chest pain.

[Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function]. / Características de los pacientes ingresados por insuficiencia cardíaca según el estado de su función ventricular.

OBJECTIVES: To compare the clinical characteristics of hospitalized patients with congestive heart failure and left ventricular dysfunction versus normal systolic function. METHODS: Clinical records of all admissions with a heart failure diagnostic code over a one-year period were reviewed retrospectively. Of 1,953 admissions, 595 were excluded because they did not fulfill diagnostic criteria. RESULTS: A total of 1,069 patients had 1,358 admissions with confirmed heart failure (1.27 admissions/patient). Of them, 706 patients (66%) had an echocardiographic study and 381 (54%) had ventricular dysfunction. Ventricular dysfunction was associated with previous myocardial infarction (OR = 5.8), left bundle-branch block (OR = 5.0), male sex (OR = 2.0), and smoking (OR = 1.8). Meanwhile, a negative association existed with age (OR = 0.97), previous valve surgery (OR = 0.46) and atrial fibrillation (OR = 0.49). Patients with ventricular dysfunction had more hospitalizations in the cardiology department and received more vasodilators, aspirin, and nitrates on discharge. The prescription of angiotensin converting enzyme inhibitors prescription to patients with ventricular dysfunction increased with the severity of ventricular dysfunction and was more frequent in patients admitted to the cardiology department. Systolic dysfunction increased hospital mortality (OR = 2.9). CONCLUSIONS: Patients admitted with heart failure and systolic dysfunction had a different clinical profile than patients with a normal ejection fraction. Seven clinical variables predicted the presence of systolic dysfunction. Patients with ventricular dysfunction had more hospital mortality and were prescribed vasodilators, aspirin, and nitrates more often on discharge.