[Right hemitruncus in adulthood: an unusual finding]. / Hemitruncus derecho en la vida adulta: un hallazgo poco usual.

Hemitruncus arteriosus is a rare congenital heart disease characterized by the abnormal origin of one of the branches of the pulmonary artery from the ascending aorta. In most cases, its diagnosis is made during childhood; in addition, due to its high morbidity and mortality, its asymptomatic evolution and survival to adulthood is extremely unusual. We present the case of a 30-year-old male patient, with a history of surgical closure of patent ductus arteriosus during childhood, who was asymptomatic until a year ago, in whom hemitruncus arteriosus was diagnosed after recurrent episodes of hemoptysis.

Reducing Dental Anxiety in Children Using a Mobile Health App: Usability and User Experience Study.

BACKGROUND: Dentistry interventions cause common anxiety and fear problems in children (6-11 years), and according to scientific evidence, this causes a decrease in their quality of life. Therapies mediated by IT-based tools have been shown to positively influence children's mood based on distraction as well as relaxing activities, but there is no evidence of their use to reduce dental anxiety in children. OBJECTIVE: The aim of this study was to answer the following research question: Does our new children-centered codesign methodology contribute to achieving a usable mobile-based product with a highly scored user experience? METHODS: A mobile health app was developed to reduce dental anxiety in children using rapid application development following the usage-centered design methodology. Structured interviews were conducted to test the usability and user experience of the app prototype among 40 children (n=20, 50%, boys and n=20, 50%, girls; age 6-11 years) using a children-adapted questionnaire and the 7-point Single Ease Question rating scale. The Smiley Faces Program-Revised questionnaire was used to assess the level of dental anxiety in participants. RESULTS: There were no significant differences between girls and boys. The task completion rate was 95% (n=19) for children aged 6-8 years (group 1) and 100% (n=20) for children aged 9-11 years (group 2). Group 1 found watching the relaxing video (task C) to be the easiest, followed by playing a video minigame (task B) and watching the narrative (task A). Group 2 found task C to be the easiest, followed by task A and then task B. The average time spent on the different types of tasks was similar in both age groups. Most of the children in both age groups were happy with the app and found it funny. All children thought that having the app in the waiting room during a dental visit would be useful. CONCLUSIONS: The findings confirmed that the app is usable and provides an excellent user experience. Our children-adapted methodology contributes to achieving usable mobile-based products for children with a highly scored user experience.

[Clinical profile and therapeutic strategies in patients with arrhythmogenic cardiomyopathy treated in a national reference institute]. / Perfil clínico y estrategias terapéuticas en pacientes con miocardiopatía arritmogénica tratados en un instituto de referencia nacional.

Objective: To determine the epidemiological, clinical, electrocardiographic, imaging characteristics and main therapeutic strategies performed in patients with arrhythmogenic cardiomyopathy treated in a national reference cardiovascular institute. Materials and methods: Observational, descriptive and retrospective study that attempts to identify the clinical characteristics, complementary tests and therapeutic strategies performed in patients with arrhythmogenic cardiomyopathy treated at the Instituto Nacional Cardiovascular - INCOR EsSalud in Lima, Peru. Results: Thirteen patients were found with arrhythmogenic cardiomyopathy. The median age at which the diagnosis was made was 38.2 years and 69.3% were male. The most frequent clinical manifestations were tachycardic palpitations (92.3%), presyncope (84.6%) and heart failure (69.2%). 23% of the patients suffered a cardiac arrest. All the patients presented at least one episode of ventricular tachycardia, 92.3% with complete left bundle branch block morphology and upper axis. 76.9% received an implantable cardioverter defibrillator (ICD), 15.3% underwent ablation and 15.3% received a heart transplant. 84.6% of the patients live to this day. Conclusions: Arrhythmogenic cardiomyopathy predominantly affected the young and male population. All the patients had a potentially fatal ventricular arrhythmia. Biventricular disease by echocardiography and cardiac magnetic resonance occurred in 69.2% and 100% of the cases, respectively. The therapeutic strategies used were antiarrhythmic medical treatment, placement of an ICD as secondary prevention, ablation, and heart transplantation. To date, 84.6% of patients survive.

[Ablation of cardiac arrhythmias using a three-dimensional electro-anatomical mapping system in the Instituto Nacional Cardiovascular - INCOR]. / Ablación de arritmias cardiacas empleando un sistema de mapeo electroanatómico tridimensional en el Instituto Nacional Cardiovascular - INCOR.

Objective: To describe the initial experience in ablation of cardiac arrhythmias using 3D mapping at the Instituto Nacional Cardiovascular INCOR (Lima, Peru). Methods: A retrospective descriptive study was carried out. During February 2020, data was collected from the medical records of all patients in whom ablation was performed using 3D mapping from July 2017 to December 2019. This procedure was performed in patients with symptomatic arrhythmia refractory to antiarrhythmic therapy. Results: Data were collected from 123 patients (median age: 46 years, 64.2% male), who had a median time of illness of 6 years. Among the arrhythmias treated, 19% had atrial fibrillation, 17.5% atrial tachycardia, 17.5% idiopathic ventricular arrhythmias, 16.6% Wolf Parkinson White syndrome / Atrioventricular reentrant tachycardia, 11.1% ventricular arrhythmias of the His-Purkinje conduction system, 9.5% scar related ventricular tachycardia associated, 6.4% atrial flutter and 2.4% intranodal tachycardia. The median fluoroscopy time was 26 minutes. Ablation was acutely successful in 95.9% of cases, acute complications were observed in 4.8%, and recurrence-free survival during the first year of follow-up was 74%. Conclusions: Our experience in ablation of cardiac arrhythmias using 3D mapping had a high acute success rate, low frequency of complications, and one-year recurrence-free survival of 74 %.

Clinical Prognosis of Right-Sided Infective Endocarditis not Associated with Cardiac Devices or Intravenous Drug use: a Cohort Study and Meta-Analysis.

Right-sided infective endocarditis (RSIE), classically associated with intravenous drug use or intracardiac devices, is considered a good-prognosis infective endocarditis (IE) form. However, predisposing factors and prognosis for "NODID" RSIE (NOt associated with cardiac Devices or Intravenous Drug use) remain unclear. The aim of this study was to evaluate predisposing factors and prognosis of NODID RSIE compared to other RSIE forms. A retrospective cohort study (January 2008-January 2019) was conducted in a reference center on 300 patients diagnosed with IE. Endocarditis-related events were defined as related to IE in mortality or open-heart surgery during follow-up. A review and meta-analysis of associated literature (January 2008-January 2019) were also performed. Fifty-seven patients presented RSIE (19%), 22 of which were NODID RSIE (39%). Use of intravascular catheters (23% vs 3%; p = 0.027) and congenital heart diseases (18% vs 0%; p = 0.019) were associated with NODID RSIE. This group had a higher in-hospital mortality (23% vs 3%; p = 0.027) and endocarditis-related event rates (41% vs 6%; p = 0.001) than non-NODID RSIE. Furthermore, NODID RSIE was independently associated with in-hospital endocarditis-related events (OR = 19.29; 95%CI:2.23-167.16; p = 0.007). Our meta-analysis evaluated four studies and identified 96 cases (30%) of NODID RSIE from 320 total RSIE cases. NODID RSIE patients demonstrated higher in-hospital mortality (RR = 2.81; 95%CI:1.61-4.90; p < 0.001; I2 = 0.0%) and necessity of open-heart surgery (RR = 13.89; 95%CI:4.14-46.60; p < 0.001; I2 = 0.0%) than non-NODID RSIE cases. Our study suggests that NODID RSIE has the highest endocarditis-related event rate and in-hospital mortality among RSIE cases and therefore should not be considered a good-prognosis IE.

Medical management of connector pin thrombosis with the Amplatzer cardiac plug left atrial closure device.

Transcatheter closure of the left atrial appendage with the Amplatzer™ cardiac plug device and double antiplatelet treatment for 3 mo has become an alternative treatment for patients with atrial fibrillation at high embolism risk and contraindications for chronic oral anticoagulation. The inadequate implantation of the left atrial appendage closure device and the discontinuation of double antiplatelet therapy are well-known as factors related to device thrombosis. Nevertheless, device thrombosis after adequate implantation requiring surgical treatment or restarting chronic oral anticoagulation has been reported and can reach 15% of patients. The connector pin thrombosis of the Amplatzer™ cardiac plug, despite a good adherence to antiplatelet treatment, has been recently described as a potential mechanism for device thrombosis. Our clinical case reports the management of this condition for the first time, showing that the early detection of thrombotic complications by transesophageal echocardiography permits solving this serious complication with medical treatment only.

Gut pH as a limiting factor for digestive proteolysis in cultured juveniles of the gilthead sea bream (Sparus aurata).

After the development of the gastric function in juvenile fish, dietary proteins enter a two-phase digestive process comprising an acidic gastric phase followed by an alkaline intestinal phase. However, the main gastric protease, pepsin, is strictly dependent on the existence of a low-enough environmental pH. In 20-g gilthead sea bream, Sparus aurata, the mean minimal gastric pH is close to 4.5, while the mean pH in the duodenal portion of the intestine was nearly fixed at 6.5. The mean maximal gastric content of HCl was approximately 20 microEq for a low-buffering diet. Gastric proteases were more severely affected than intestinal proteases when assayed at actual sub-optimal pH values, 4.5 and 6.5, respectively. When the gastric proteases of juvenile fish were pre-incubated with a citric acid buffer at pH 6.0, the activity at pH 4.5 was very low, whereas when they were pre-incubated with the same buffer at pH 3.0, the activity at pH 4.5 was significantly increased; this fact suggests a deficient activation of zymogens during the gastric digestion and points to a potential approach to improve protein digestion in juvenile gilthead sea bream.

Prognostic implications of arterial blood gases in acute decompensated heart failure.

BACKGROUND: The prognostic value of arterial blood gases (ABG) in patients with acute decompensated heart failure (ADHF) is not well-established. We therefore conducted the present study to determine the relationship between ABG on admission and long-term mortality in patients with ADHF. METHODS: We studied 588 patients consecutively admitted to our department with ADHF. ABG and classical prognostic variables were determined at patients' arrival to the emergency department. The independent association among the main variables of ABG (pO2, pCO2 and pH) and mortality was assessed with Cox regression analysis. RESULTS: At a median follow-up of 23months, 221 deaths (37.6%) were registered. 308 (52.4%), 54 (9.2%) and 50 (8.5%) patients showed hypoxemia (pO2<60mmHg), hypercapnia (pCO2>50mmHg) and acidosis (pH<7.35), respectively. Patients with hypoxemia, hypercapnia and acidosis did not show higher mortality rates (38% vs. 37.1%, 42.6% vs. 37.1%, and 48% vs. 36.6%, respectively; p-value=ns for all comparisons). In multivariate analysis, after adjusting for well-known prognostic covariates, pO2, pCO2 and pH did not show a significant association with mortality. Hazard ratios (HR) for these variables were: pO2, per increase in 10mmHg: 0.99 (95% CI: 0.90-1.09), p=0.861; pCO2, per increase in 10mmHg: 1.12 (95% CI: 0.91-1.39), p=0.262; pH per increase in 0.1: 1.01 (95% CI: 0.99-1.04), p=0.309. When dichotomizing these variables according to established cut-points, the HR were: hypoxemia (pO2<60mmHg):1.07 (95% CI: 0.81-1.40), p=0.637; hypercapnia (pCO2>50mmHg): 0.98 (95% CI: 0.62-1.57), p=0.952; acidosis (pH<7.35): 1.38 (95% CI: 0.87-2.19), p=0.173. CONCLUSION: In patients admitted with ADHF, admission arterial pO2, pCO2 and pH were not associated with all-cause long-term mortality.

Hyperuricemia in acute heart failure. More than a simple spectator?

BACKGROUND: Hyperuricemia is a prevalent condition in chronic heart failure (CHF), describing increased oxidative stress and inflammation. Although there is evidence that serum uric acid (UA) predicts mortality in CHF, its role as a prognostic biomarker in acute heart failure (AHF) has not yet been well assessed. The aim of this study was to determine if UA levels predict all-cause mortality. Additionally, as a secondary endpoint we sought the clinical predictors of UA serum level in this population. METHODS: We analyzed 560 consecutive patients with AHF admitted in a single university center. UA (mg/dl) was measured during early hospitalization. Patient survival status was followed up after discharge (median follow-up: 330 days). The independent association of UA level with all-cause mortality was analyzed using Cox regression analysis. RESULTS: During follow-up 165 (29.5%) deaths were identified. Patients with UA levels above the median value (>or=7.7 mg/dl) exhibited higher mortality rates (21.1 vs. 37.9%; p<0.001). In multivariable analysis, after adjusting for recognized prognostic factors and potential confounders, UA>or=7.7 mg/dl and per change in 1 mg/dl of UA was associated with an increased risk of mortality (HR 1.45, CI 95%=1.03-2.44; p=0.03 and HR 1.08, CI 95%=1.01-1.15; p=0.03, respectively). CONCLUSION: UA serum levels is an independent predictor of all-cause mortality in an unselected patients admitted with AHF.

Prognostic value of brain natriuretic peptide in acute heart failure: mortality and hospital readmission.

The prognostic value of brain natriuretic peptide (BNP) measurement in patients with acute heart failure is not well understood. The aim of this study was to investigate the relationship between the BNP level and mortality and readmission for acute heart failure. We studied 569 consecutive patients who were admitted with a diagnosis of acute heart failure. The BNP level was measured after the patient became clinically stable. The relationship between the BNP level and mortality was assessed by Cox regression analysis, and the relationship with readmission, by competing risks regression analysis. During a median follow-up period of 9 (range, 3-18) months, 156 deaths (27.4%) and 140 readmissions (24.6%) occurred. Multivariate analysis demonstrated a positive linear association between the risk of death and the BNP quintile. In contrast, the BNP level did not predict readmission for acute heart failure, mainly because of the effect of death as a competing outcome.

Implicaciones pronósticas del péptido natriurético cerebral en la insuficiencia cardiaca aguda: mortalidad y reingresos hospitalarios / Prognostic value of brain natriuretic peptide in acute heart failure: mortality and hospital readmission

El valor pronóstico del péptido natriurético cerebral (BNP) tras un episodio de insuficiencia cardiaca aguda (ICA) no ha sido totalmente establecido. El objetivo de este trabajo fue evaluar la relación entre las concentraciones de BNP y la mortalidad y los reingresos por ICA. Analizamos a 569 pacientes ingresados consecutivamente con el diagnóstico de ICA. Se determinó el BNP tras la estabilización inicial del paciente. La relación entre el BNP y la mortalidad fue evaluada mediante regresión de Cox y la relación con el reingreso, mediante regresión con ajuste para episodios competitivos. Durante una mediana de seguimiento de 9 (3-18) meses, se registraron 156 muertes (27,4%) y 140 reingresos (24,6%). En el análisis multivariable se observó una asociación positiva y lineal entre el riesgo de mortalidad y los quintiles de BNP. Para reingreso por ICA, el BNP no mostró tener valor predictivo debido al efecto de la mortalidad como episodio competitivo (AU)

The prognostic value of brain natriuretic peptide (BNP) measurement in patients with acute heart failure is not well understood. The aim of this study was to investigate the relationship between the BNP level and mortality and readmission for acute heart failure. We studied 569 consecutive patients who were admitted with a diagnosis of acute heart failure. The BNP level was measured after the patient became clinically stable. The relationship between the BNP level and mortality was assessed by Cox regression analysis, and the relationship with readmission, by competing risks regression analysis. During a median follow-up period of 9 (range, 3-18) months, 156 deaths (27.4%) and 140 readmissions (24.6%) occurred. Multivariate analysis demonstrated a positive linear association between the risk of death and the BNP quintile. In contrast, the BNP level did not predict readmission for acute heart failure, mainly because of the effect of death as a competing outcome (AU)

Limitations of clinical history for evaluation of patients with acute chest pain, non-diagnostic electrocardiogram, and normal troponin.

Decision making and risk stratification for patients with acute chest pain, nondiagnostic electrocardiogram results, and normal troponin levels are challenging. The aim of this study was to optimize the clinical history for the evaluation of these patients. A total of 1,011 patients presenting to an emergency department were included. The following data were collected: clinical presentation (pain characteristics and number of pain episodes), coronary risk factors, previous ischemic heart disease, and extracardiac vascular disease (peripheral artery disease, stroke, or creatinine >1.4 mg/dl). Two different predictive models were calculated according to the end points: model 1 for 1-year major events (death or myocardial infarction) and model 2 for 30-day cardiac events (major events or revascularization). For 1-year major events, model 1 showed optimal discrimination capacity (C statistic = 0.80), which was significantly better than that of model 2 (C statistic = 0.77, p = 0.04). With respect to 30-day cardiac events, however, discrimination was lower in the 2 models, without differences between them (C statistic = 0.74 vs 0.75, p = NS). Using model 1, a large low-risk subgroup with <3 predictive variables could be defined, including 442 patients (44% of the total population) with a 1.4% rate of 1-year major events; however, the incidence of 30-day cardiac events (8%) was not negligible, mainly because of revascularizations. In conclusion, in patients with acute chest pain of uncertain coronary origin, clinical predictive models afford good risk stratification for long-term major events. Short-term outcomes, including revascularization, however, are not predicted as well. Therefore, ancillary tools, such as noninvasive stress tests, should be implemented for decision making at initial hospitalization or discharge.

Carbohydrate antigen 125: an emerging prognostic risk factor in acute heart failure?

OBJECTIVE: To assess whether circulating levels of carbohydrate antigen 125 (CA125) predict subsequent 6-month all-cause mortality in patients after the index hospitalisation for acute heart failure (HF). DESIGN AND SETTING: Prospective cohort study at a single teaching centre in Spain. METHODS: 529 consecutive patients with acute HF admitted in a single university centre were analysed. In addition to the traditional clinical information, CA125 (U/ml) was measured during the early course of hospitalisation. The independent association between baseline CA125 and mortality was assessed with Cox regression analysis. The follow-up was limited to 6 months. RESULTS: 349 (66%) patients showed serum levels of CA125 >35 U/ml (established cut-off point value). At a 6-month follow-up, 89 (16.8%) deaths were identified. A positive trend between mortality and CA125 quartiles was observed; 3.8%, 15.2%, 22% and 26.5% of deaths occurred from quartile 1 to 4 of CA125 (p<0.001). Likewise, a monotonic, ascending trend in the risk ratios was estimated from the multivariable Cox model. Compared with the first quartile of CA125, the HRs (95% CI) for the second, third and fourth quartiles were 3.25 (1.20 to 8.79), 4.91 (1.88 to 12.85) and 8.41 (3.24 to 21.79), respectively. CONCLUSIONS: Serum levels of CA125 obtained in patients admitted with a diagnosis of acute HF was shown to be an independent predictor of mortality up to the 6-month follow-up.

[Prognostic impact of anemia in acute heart failure]. / Impacto pronóstico de la anemia en insuficiencia cardiaca aguda.

BACKGROUND AND AIM: Studies performed on selected patients in other countries have shown that anemia is frequently associated with heart failure and results in a worse prognosis. We sought to determine the prognosis significance of hemoglobin/anemia in patients with acute heart failure which required management with hospital admission. MATERIAL AND METHODS: We analysed 412 patients diagnosed with acute heart failure as outlined in the criteria of the European Society of Cardiology (ESC). We measured hemoglobin within the first 24 hours and obtained demographic, clinical and biochemical variables. Anemia was defined in accordance with OMS criteria. The main variable was all-cause mortality. The association between all-cause mortality and hemoglobin/anemia was determined using the multiple regression Cox model. RESULTS: During follow-up (median six months) we observed 101 all-cause mortality events. In the multivariate analysis, hemoglobin was an independent predictive variable adjusted by covariates (HR 1.15, IC 95% [1.04-1.25], p = 0.014). Anemia (hemoglobin < 13 g/dL) was also found to be an independent predictive variable adjusted by covariates (HR 2.06, IC al 95% [1.28-3.33], p = 0.003). CONCLUSIONS: Hemoglobin and anemia (hemoglobin < 13 g/dL) are consistently associated with short-term, poorer survival in patients with acute heart failure.

Impacto pronóstico de la anemia en insuficiencia cardiaca aguda / Prognostic impact of anemia in acute heart failure

Background and aim. Studies performed on selected patients in other countries have shown that anemia is frequently associated with heart failure and results in a worse prognosis. We sought to determine the prognosis significance of hemoglobin I anemia in patients with acute heart failure which required management with hospital admission. Material and Methods. We analysed 412 patients diagnosed with acute heart failure as outlined in the criteria of the European Society of Cardiology (ESC). We measured hemoglobin within the first 24 hours and obtained demographic, clinical and biochemical variables. Anemia was defined in accordance with OMS criteria. The main variable was all-cause mortality. The association between all-cause mortality and hemoglobin I anemia was determined using the multiple regression Cox model. Results. During follow-up (median six months) we observed 101 all-cause mortality events. In the multivariate analysis, hemoglobin was an independent predictive variable adjusted by covariates (HR 1.15, IC 95% [1.04-1.25], p = 0.014). Anemia (hemoglobin < 13 g/dL) was also found to be an independent predictive variable adjusted by covariates (HR 2.06, IC al 95% [1.28-3.33], p = 0.003). Conclusions. Hemoglobin and anemia (hemoglobin < 13 g/dL) are consistently associated with short-term, poorer survival in patients with acute heart failure.

Fundamento y objetivo. La anemia en la insuficiencia cardiaca aguda es un hallazgo frecuente y parece implicar un peor pronóstico. Sin embargo, la mayor parte de estos datos provienen de series extranjeras y población seleccionada. Nuestro objetivo fue conocer en nuestro medio y en población no seleccionada el grado de asociación entre las cifras de hemoglobina al ingreso y la mortalidad por todas las causas a corto plazo tras un ingreso hospitalario por insuficiencia cardiaca aguda. Material y métodos. Incluimos consecutivamente 412 enfermos ingresados en el Servicio de Cardiología diagnosticados de insuficiencia cardiaca aguda según la Sociedad Europea de Cardiología (ESC). Se determinó la hemoglobina al ingreso, así como un conjunto de variables epidemiológicas, clínicas y bioquímicas de contrastado valor pronóstico. La asociación entre mortalidad por todas las causas para la hemoglobina y anemia se determinó mediante un modelo de riesgos proporcionales de Cox. Resultados. Durante el seguimiento de la muestra (mediana seis meses) se registraron 101 muertes por cualquier causa. El descenso de 1 g/dL de hemoglobina se asoció de manera independiente con la mortalidad (IR 1.15, IC 95% [1.04-1.25], p = 0.014). De esta misma manera, la presencia de anemia (hemoglobina < 13 g/dL) al ingreso se asoció de manera independiente con la mortalidad total (IR 2.06, IC 95% [1.28-3.33], p = 0.003). Conclusiones. En pacientes ingresados por insuficiencia cardiaca aguda la hemoglobina (continua o dicotomizada según criterios OMS/ WHO) se asoció de manera independiente e intensa con un desenlace fatal a corto plazo.