Cardiac amyloidosis in Latin America: Gaps and opportunities to increase awareness of the disease. Findings from the AMILO-LATAM research group.

BACKGROUND: Cardiac amyloidosis (CA) is an under-diagnosed disease presenting as a restrictive cardiomyopathy with high morbidity and mortality. Wild-type transthyretin amyloid cardiomyopathy (ATTR-CM) is mostly seen in elderly patients, with increasing prevalence as life expectancy is growing. New diagnostic imaging techniques and treatments allow for a better prognosis, but lack of clinical awareness delays timely diagnosis and appropriate management. Our purpose was to investigate the knowledge of clinicians regarding ATTR-CM and to assess the availability of imaging resources in the Latin-American region. METHODS AND RESULTS: Two online surveys were distributed among clinicians and nuclear medicine professionals, respectively: one asking about awareness of CA in different clinical scenarios, and the other about the availability of diagnostic resources and studies performed. 406 responses were received for the first survey and 82 for the second, representing 17 and 14 countries, respectively. A significant lack of awareness was identified among clinicians, although appropriate diagnostic resources are generally available. Survey data showed that very few patients are evaluated for ATTR-CM in most Latin-American countries. CONCLUSIONS: The surveys demonstrated the need for educational programs and other measures to increase clinical awareness and early detection of CA, so patients receive timely treatment and management of the disease.

Coronary Artery Disease in Women: Getting to Know Gender Related Disparities

Abstract Coronary artery disease (CAD) and ischemic heart disease (IHD) are often indistinctly used terms. Both combined have generated, over the past years, concerns about sex disparities in their presentation. From an epidemiological perspective, females have several disadvantages regarding the prevention, diagnosis, and treatment of CAD. Most of the general cardiovascular risk factors affect women more frequently, or with a higher morbidity and mortality association. Besides, atypical manifestations of the disease and uncommon forms of CAD represent a diagnostic challenge for clinicians. Even if current treatments for CAD have no apparent sex bias, women representation in clinical trials and treatment patterns analyzed in clinical practice refuse this statement. Several disparities are caused by inevitable sex-particularities, but many of them are more social, cultural, and dogmatic beliefs that have to be addressed and overhaul.

Reproducibility of global LV function and dyssynchrony parameters derived from phase analysis of gated myocardial perfusion SPECT: A multicenter comparison with core laboratory setting.

BACKGROUND: Gated myocardial perfusion scintigraphy (GMPS) phase analysis is an important tool to investigate the physiology of left ventricular (LV) dyssynchrony. We aimed to test the performance of GMPS LV function and phase analysis in different clinical settings and on a diverse population. METHODS: This is a post hoc analysis of a prospective, non-randomized, multinational, multicenter cohort study. Clinical evaluation and GMPS prior to cardiac resynchronization therapy (CRT)(baseline) and 6-month post CRT (follow-up) were done. LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV), LV ejection fraction (LVEF), LV phase standard deviation (LVPSD), and percentage of left ventricle non-viable (PLVNV) were obtained by 10 centers and compared to the core lab. RESULTS: 276 GMPS studies had all data available from individual sites and from core lab. There were no statistically significant differences between all variables except for LVPSD. When subjects with no mechanical dyssynchrony were excluded, LVPSD difference became non-significant. LVESV, LVEF, LVPSD and PLVNV had strong correlation in site against core lab comparison. Bland-Altman plots demonstrated good agreement. CONCLUSIONS: The presented correlation and agreement of LV function and dyssynchrony analysis over different sites with a diverse sample corroborate the strength of GMPS in the management of heart failure in clinical practice.

Clinical and gated SPECT MPI parameters associated with super-response to cardiac resynchronization therapy.

PURPOSE: We sought to evaluate the behavior of cardiac mechanical synchrony as measured by phase SD (PSD) derived from gated MPI SPECT (gSPECT) in patients with super-response after CRT and to evaluate the clinical and imaging characteristics associated with super-response. METHODS: 158 subjects were evaluated with gSPECT before and 6 months after CRT. Patients with an improvement of LVEF > 15% and NYHA class I/II or reduction in LV end-systolic volume > 30% and NYHA class I/II were labeled as super-responders (SR). RESULTS: 34 patients were classified as super-responders (22%) and had lower PSD (32° ± 17°) at 6 months after CRT compared to responders (45° ± 24°) and non-responders 46° ± 28° (P = .02 for both comparisons). Regression analysis identified predictors independently associated with super-response to CRT: absence of previous history of CAD (odds ratio 18.7; P = .002), absence of diabetes mellitus (odds ratio 13; P = .03), and history of hypertension (odds ratio .2; P = .01). CONCLUSION: LV dyssynchrony after CRT implantation, but not at baseline, was significantly better among super-responders compared to non-super-responders. The absence of diabetes, absence of CAD, and history of hypertension were independently associated with super-response after CRT.

Value of intraventricular dyssynchrony assessment by gated-SPECT myocardial perfusion imaging in the management of heart failure patients undergoing cardiac resynchronization therapy (VISION-CRT).

BACKGROUND: Placing the left ventricular (LV) lead in a viable segment with the latest mechanical activation (vSOLA) may be associated with optimal cardiac resynchronization therapy (CRT) response. We assessed the role of gated SPECT myocardial perfusion imaging (gSPECT MPI) in predicting clinical outcomes at 6 months in patients submitted to CRT. METHODS: Ten centers from 8 countries enrolled 195 consecutive patients. All underwent gSPECT MPI before and 6 months after CRT. The procedure was performed as per current guidelines, the operators being unaware of gSPECT MPI results. Regional LV dyssynchrony (Phase SD) and vSOLA were automatically determined using a 17 segment model. The lead was considered on-target if placed in vSOLA. The primary outcome was improvement in ≥1 of the following: ≥1 NYHA class, left ventricular ejection fraction (LVEF) by ≥5%, reduction in end-systolic volume by ≥15%, and ≥5 points in Minnesota Living With Heart Failure Questionnaire (MLHFQ). RESULTS: Sixteen patients died before the follow-up gSPECT MPI. The primary outcome occurred in 152 out of 179 (84.9%) cases. Mean change in LV phase standard deviation (PSD) at 6 months was 10.5°. Baseline dyssynchrony was not associated with the primary outcome. However, change in LV PSD from baseline was associated with the primary outcome (OR 1.04, 95% CI 1.01-1.07, P = .007). Change in LV PSD had an AUC of 0.78 (0.66-0.90) for the primary outcome. Improvement in LV PSD of 4° resulted in the highest positive likelihood ratio of 7.4 for a favorable outcome. In 23% of the patients, the CRT lead was placed in the vSOLA, and in 42% in either this segment or in a segment within 10° of it. On-target lead placement was not significantly associated with the primary outcome (OR 1.53, 95% CI 0.71-3.28). CONCLUSION: LV dyssynchrony improvement by gSPECT MPI, but not on-target lead placement, predicts clinical outcomes in patients undergoing CRT.

Clinical impact of the polypill for cardiovascular prevention in Latin America: a consensus statement of the Inter-American Society of Cardiology

The burden of cardiovascular diseases (CVD) is increasing, particularly in low-middle-income countries such as most of Latin America. This region presents specific socioeconomic characteristics, generating a high incidence of CVD despite efforts to control the problem. A consensus statement has been developed by Inter-American Society of Cardiology with the aim of answering some important questions related to CVD in this region and the role of the polypill in cardiovascular (CV) prevention as an intervention to address these issues. A multidisciplinary team composed of Latin American experts in the prevention of CVD was convened by the Inter-American Society of Cardiology and participated in the process and the formulation of statements. To characterize the prevailing situation in Latin American countries, we describe the most significant CV risk factors in the region. The barriers that impair the use of CV essential medications are also reviewed. The role of therapeutic adherence in CV prevention and how the polypill emerges as an effective strategy for optimizing adherence, accessibility, and affordability in the treatment of CVDs are discussed in detail. Clinical scenarios in which the polypill could represent an effective intervention in primary and secondary CV prevention are described. This initiative is expected to help professionals involved in the management of CVD and public health policymakers develop optimal strategies for the management of CVDs. (AU)

Clinical Impact of the Polypill for Cardiovascular Prevention in Latin America A Consensus Statement of the Inter-American Society of Cardiology

ABSTRACT: The burden of cardiovascular diseases (CVD) is increasing, particularly in low-middle-income countries such as most of Latin America. This region presents specific socioeconomic characteristics, generating a high incidence of CVD despite efforts to control the problem. A consensus statement has been developed by Inter-American Society of Cardiology with the aim of answering some important questions related to CVD in this region and the role of the polypill in cardiovascular (CV) prevention as an intervention to address these issues. A multidisciplinary team composed of Latin American experts in the prevention of CVD was convened by the Inter-American Society of Cardiology and participated in the process and the formulation of statements. To characterize the prevailing situation in Latin American countries, we describe the most significant CV risk factors in the region. The barriers that impair the use of CV essential medications are also reviewed. The role of therapeutic adherence in CV prevention and how the polypill emerges as an effective strategy for optimizing adherence, accessibility, and affordability in the treatment of CVDs are discussed in detail. Clinical scenarios in which the polypill could represent an effective intervention in primary and secondary CV prevention are described. This initiative is expected to help professionals involved in the management of CVD and public health policymakers develop optimal strategies for the management of CVDs.

Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS).

BACKGROUND: Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC. METHODS AND RESULTS: INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight "best practices" were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of 99mTc could be adjusted reflecting patient weight/habitus. CONCLUSIONS: On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the "as low as reasonably achievable" (ALARA) principle.

Estenosis aórtica supravalvular: reporte de caso clínico y revisión bibliográfica / Supravalvular aortic stenosis: clinical case report and review

Resumen La estenosis aórtica supravalvular es una lesión congénita obstructiva del tracto de salida del ventrículo izquierdo. Es la forma menos frecuente dentro de este grupo de lesiones, las cuales, a su vez representan el 6% de las cardiopatías congénitas en pacientes pediátricos. Esta cardiopatía se relaciona más con pacientes pediátricos, sin embargo, presentamos el caso de un paciente masculino de 23 años de edad quien acudió al hospital por haber presentado episodio de disnea súbita en reposo, acompañada de diaforesis, dolor torácico opresivo sin irradiaciones y síncope. Se realizó un ecocardiograma transtorácico con el cual se diagnosticó estenosis aórtica supravalvular.

Abstract Supravalvular aortic stenosis is a left ventricular outflow tract obstructive lesion. It is the least common form of this group of lesions, which only represents 6% of congenital heart disease in children. This condition is commonly diagnosed during childhood; however we present the case of a 23 year old man who was taken to the hospital for having presented a sudden dyspnea episode with diaphoresis, chest pain without radiation and syncope. He was diagnosed with supravalvular aortic stenosis after echocardiography.

Orbital positron emission tomography/computed tomography (PET/CT) imaging findings in Graves ophthalmopathy.

BACKGROUND: We aimed to describe orbital positron emission tomography/computed tomography (PET/CT) imaging findings, both structural and metabolic, in different clinical stages of Graves ophthalmopathy (GO). This prospective, observational, cross-sectional study examined 32 eyes of 16 patients with GO. METHODS: Patients were assessed with a complete ophthalmological evaluation and assigned a VISA classification for GO. All patients underwent serum thyroid hormone measurement, antibody profile, and 18-fluorodeoxyglucose positron emission tomography/computed tomography (18-FDG PET/CT) of the orbits. The 18-FDG uptake on PET images was expressed in terms of maximum standard uptake value (SUVmax). CT images were analyzed, and orbital structures were measured in millimeters. Vision, inflammation, strabismus, and overall appearance were assessed according to the VISA classification system, thyroid hormone levels, antibody values, 18-FDG uptake, and thickness of orbital structures. RESULTS: Altogether, 32 eyes of 16 patients (10 women, 6 men; mean age 44.31 ± 13 years, range 20-71 years) were included. Three patients were hypothyroid, seven were euthyroid, and six were hyperthyroid. CT measurements of extraocular muscle diameter were elevated (P < 0.05), and muscle 18-FDG uptake values were increased. Eyes with a clinical VISA inflammation score of ≤ 4 had an average extraocular muscle SUVmax of 3.09, and those with a score of ≥ 5 had an average SUVmax of 3.92 (P = 0.09), showing no clear correlation between clinically observed inflammation and 18-FDG uptake. 18-FDG uptake values also did not show a correlation with extraocular muscle diameter as measured by CT (R2 = 0.0755, P > 0.05). CONCLUSIONS: We demonstrated a lack of correlation between 18-FDG extraocular muscle uptake and either clinical inflammation score or muscle diameter. Although 18-FDG uptake has been used as an inflammation marker in other pathologies, inflammation in GO may be clinically detected in PET/CT-negative cases, and cases with negative clinical findings may show inflammation on PET/CT. Clinical evaluation is mandatory but may be insufficient and inaccurate for classifying GO. A larger and homogeneous sample size and further research is needed to define the role of PET/CT in detecting, grading, and follow-up of GO to optimize treatment of the inflammatory stage respect clinical methods currently used.

18-Fluorodeoxyglucose Uptake by Positron Emission Tomography in Extraocular Muscles of Patients with and without Graves' Ophthalmology.

Objective. To compare 18-fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET) in extraocular muscles (EOMs) of patients with Graves' ophthalmopathy (GO) versus patients without GO. Design. Prospective, observational, comparative, and cross-sectional study. Participants. Thirty-two eyes of patients with GO and seventy eyes of patients without GO. Methods. We prospectively included patients older than 18 years of age with and without GO. FDG-PET imaging study was performed; standardized unit value (SUVmax) was quantified in EOMs. Standard deviation and significant statistical difference (P < 0.05) were calculated. Results. Thirty-two eyes of sixteen patients of the GO group were included, with a mean age of 44.31 (20-71) years. Seventy eyes of thirty-five patients of the group without GO were included, with a mean age of 49.20 (24-77) years. EOMs average uptake of the groups with and without GO were 3.38 ± 1.31 and 1.89 ± 0.51 SUVmax (P < 0.05), respectively. Conclusion. FDG uptake was significantly increased in EOMs of patients with GO. PET gives valuable information and may be a helpful tool in detecting, localizing, and quantifying GO inflammation. Further research is needed to define the role of PET in detecting, grading, and following up GO in order to optimize treatment in the inflammatory stage.

Tetralogía de Fallot: reporte de un caso y revisión de la literatura / Tetralogy of Fallot: Case report and literature review

La tetralogía de Fallot es una cardiopatía congénita que se caracteriza por presentar estenosis infundibular de la arteria pulmonar, cabalgamiento aórtico, comunicación interventricular e hipertrofia del ventrículo derecho. Es la cardiopatía congénita cianógena más prevalente, representando entre el 3.5 a 8% de los defectos cardiacos congénitos. Presentamos el caso de un paciente de 6 años que acudió al hospital con cianosis peribucal y acrocianosis y episodios recurrentes de crisis hipóxicas. Se le hizo un ecocardiograma con el cual se diagnóstico tetralogía de Fallot y posteriormente se le realizó una fístula de Blalock-Taussig.

Tetralogy of Fallot is a congenital cardiopathy characterized by infundiblutar stenosis of the pulmonary artery, overriding aorta, ventricular septal defect and right ventricular hypertrophy. It is the most prevalent cyanotic congenital heart defect, with a prevalence between 3.5 to 8%. We present the case of a 6-year-old male who was taken to our hospital due to perioral and distal cyanosis and paroxistic episodes of hypoxia (tet spell), who was diagnosed with tetralogy of Fallot after echocardiography and was treated with Blalock-Taussig shunt.

Evaluation of the endothelial function in hypertensive patients with 13N-ammonia PET.

BACKGROUND: Essential hypertension is one of the main risk factors for the development of coronary artery disease (CAD). Hypertension causes endothelial dysfunction which is considered an early sign for the development of CAD. Positron emission tomography is a non-invasive imaging technique that measures myocardial blood flow (MBF), allowing us to identify patients with endothelial dysfunction. METHODS AND RESULTS: 19 patients without comorbidities recently diagnosed hypertensive, as well as 21 healthy volunteers were studied. A three-phase (rest, cold pressor test, and adenosine-induced hyperemia) (13)N-ammonia PET was performed, and MBF was measured. Endothelial-Dependent Vasodilation Index, ΔMBF, and coronary flow reserve (CFR) were calculated for each patient. Hypertensive patients had a significantly higher systolic and diastolic blood pressures compared with the control group (134.6 ± 11.7/86.4 ± 10.6 mm Hg and 106.0 ± 11.8/71.4 ± 6.6 mm Hg, respectively, P < .001). The ENDEVI (1.28 ± 0.26 vs 1.79 ± 0.30, P < .001), the ΔMBF (0.81 ± 0.50 vs 0.25 ± 0.21, P < .001) and the CFR (2.18 ± 0.88 vs 3.17 ± 0.68, P = .001) were significantly lower in the hypertensive patients compared to the control group, 84% of the former group had endothelial dysfunction i.e., ENDEVI < 1.5 and 58% had vasomotor abnormalities, i.e., CFR < 2.5. CONCLUSIONS: In this study, we showed that recently diagnosed hypertensive patients have coronary endothelial dysfunction and vasomotor disturbances which are early signs for the development of CAD.

Prognostic value of cardiovascular CT: is coronary artery calcium screening enough? The added value of CCTA.

Coronary artery disease (CAD) is the primary cause of death in adults in the United States. Only 50% of patients who present with a myocardial infarction have a prior history of CAD. Non-invasive cardiac imaging tests have been developed to diagnose CAD. Current guidelines and systematic reviews have tried to determine the prognostic value of the coronary artery calcium (CAC) scoring and the coronary computed tomography angiography (CCTA) for major adverse cardiovascular events. Several studies support the roles of CCTA and CAC scoring for the diagnosis of CAD in asymptomatic patients. Further studies are needed to confirm the superior role of CCTA over CAC scoring in symptomatic patients.

[Relationship between the ECG and MRI findings in acute myocardial infarction]. / Relación entre los hallazgos electrocardiográficos y de resonancia magnética en la fase aguda del infarto miocárdico.

OBJECTIVE: To evaluate the agreement between de ECG leads with ST elevation and the myocardial segments that present myocardial edema in the MRI study, in patients with acute myocardial infarction. METHODS: There were included 91 patients with a first ST elevation myocardial infarction (STEMI) with reperfusion therapy during the first 12 hours of onset symptoms, in whom a Cardiovascular Magnetic Resonance (CMR) was done (mean 3 day after the ischemic event). Among the ECG leads (thoracic circle), there were identified those with ST higher elevation. In the CMR there were evaluated the myocardial segments with edema (T2-weighted sequence with hyperintensity). RESULTS: The ECG leads with the best sensibility in the detection of injury, corresponding to cellular edema, were: basal anterior and anteroseptal: V2; basal inferoseptal LIII and aVF; basal inferior and inferolateral: LIII; basal anterolateral V7-V9; mid anterior and anteroseptal:V2 and V3; mid inferoseptal, inferior and inferolateral: LIII and aVF; mid anterolateral V2 and V8; apical anterior and septal: V2-V4; apical inferior and lateral: LII, LIII and aVF; apex: V2-V4. CONCLUSIONS: The surface ECG leads with higher ST elevation corresponded to the myocardial segments with more important edema (defined as someone with hyperintensity in the T2- weighted MRI sequence).

Relación entre los hallazgos electrocardiográficos y de resonancia magnética en la fase aguda del infarto miocárdico / Relationship between the ECG and MRI findings in acute myocardial infarction

Objetivo: Evaluar la relación que existe entre las derivaciones electrocardiográficas que presentan elevación del segmento ST y los segmentos miocárdicos, que presentan edema en el estudio de resonancia magnética, en la fase aguda del infarto. Métodos: Se incluyeron en el estudio 91 pacientes con un primer infarto agudo del miocardio y elevación del ST (IAMCEST), que recibieron tratamiento de reperfusión en las primeras 12 horas de inicio de los síntomas y a quienes se les realizó resonancia magnética cardiovascular (RMC) entre el primero y el séptimo día del infarto. Se analizó el círculo torácico electrocardiográfico tomado al momento del ingreso hospitalario del paciente para identificar las derivaciones con elevación del S T. En el estudio de RMC (con la secuencia T2) se identificaron los segmentos miocárdicos con edema. Se determinó cuales derivaciones electrocardiográficas tuvieron la mejor sensibilidad y especificidad en la detección de lesión miocárdica por segmento edematizado. Resultados: Las derivaciones electrocardiográficas con mejor sensibilidad para la detección de lesión por segmento con edema fueron: segmento anterior y anteroseptal en tercio basal: V2; infero-septal basal: DIII y aVF; inferior e ínfero-lateral basal: DIII; antero-lateral basal: V7-V9; anterior y antero-septal en tercio medio: V2 y V3; ínfero-septal, inferior e ínfero-lateral en tercio medio: DIII y aVF; antero-lateral en tercio medio: V2 y V8, anterior y septal tercio apical: V2-V4; inferior y lateral apical DII, DIII y aVF; ápex: V2-V4. Conclusiones: Las derivaciones del electrocardiograma de superficie con elevación del ST detectan la presencia de lesión subepicárdica, que corresponde a edema miocárdico (definido como aquel segmento con hiperintensidad en la secuencia T2-pesado). Lesión y edema se deben a despolarización diastólica parcial de las fibras miocárdicas en el infarto miocárdico agudo.

Objective:To evaluate the agreement between de ECG leads with ST elevation and the myocardial segments that present myocardial edema in the MRI study, in patients with acute myocardial infarction. Methods: There were included 91 patients with a first ST elevation myocardial infarction (STEMI) with reperfusion therapy during the first 12 hours of onset symptoms, in whom a Cardiovascular Magnetic Resonance (CMR) was done (mean 3 day after the ischemic event). Among the ECG leads (thoracic circle), there were identified those with ST higher elevation. In the CMR there were evaluated the myocardial segments with edema (T2-weighted sequence with hyperintensity). Results:The ECG leads with the best sensibility in the detection of injury, corresponding to cellular edema, were: basal anterior and anteroseptal: V2; basal inferoseptal LIII and aVF; basal inferior and inferolateral: LIII; basal anterolateral V7-V9; mid anterior and anteroseptal:V2 and V3; mid inferoseptal, inferior and inferolateral: LIII and aVF; mid anterolateral V2 and V8; apical anterior and septal: V2-V4; apical inferior and lateral: LII, LIII and aVF; apex: V2-V4. Conclusions:The surface ECG leads with higher ST elevation corresponded to the myocardial segments with more important edema (defined as someone with hyperintensity in the T2-weighted MRI sequence).

Design and implementation of the TRACIA: intracoronary autologous transplant of bone marrow-derived stem cells for acute ST elevation myocardial infarction.

OBJECTIVE: To describe the design of a protocol of intracoronary autologous transplant of bone marrow-derived stem cells for acute ST-elevation myocardial infarction (STEMI) and to report the safety of the procedure in the first patients included. METHODS: The TRACIA study was implemented following predetermined inclusion and exclusion criteria. The protocol includes procedures such as randomization, bone marrow retrieval, stem cells processing, intracoronary infusion of stem cells in the infarct-related artery, preand- post MRI, pre-and-post SPECT with radioisotope ventriculography, and clinical follow-up at 6 months. RESULTS: Eight patients with a diagnosis of acute STEMI and duration of symptoms of ?24 hours that were perfused successfully through primary percutaneous coronary intervention (PPCI) with a LVEF of ?45% were assigned randomly to two groups (n = 4 each). One group treated with stem cells and the other corresponded to the control group. Neither death, re-infarction, no need for revascularization or thrombosis of the stent were observed at follow-up. CONCLUSIONS: The initial experience at the Instituto Nacional de Cardiología Ignacio Chávez in the treatment of acute STEMI by means of autologous transplantation of bone marrow-derived stem cells is encouraging. Implementation was possible in the first eight patients with no complications.

Design and implementation of the TRACIA: intracoronary autologous transplant of bone marrow-derived stem cells for acute ST elevation myocardial infarction / Diseño e implementación del estudio TRACIA: Trasplante intracoronario Autológo de Células madre para Infarto Agudo del miocardio con elevación de segmento ST

Objective: To describe the design of a protocol of intracoronary autologous transplant of bone marrow-derived stem cells for acute ST-elevation myocardial infarction (STEMI) and to report the safety of the procedure in the first patients included. Methods: The TRACIA study was implemented following predetermined inclusion and exclusion criteria. The protocol includes procedures such as randomization, bone marrow retrieval, stem cells processing, intracoronary infusion of stem cells in the infarct-related artery, pre-and-post MRI, pre-and-post SPECT with radioisotope ventriculography, and clinical follow-up at 6 months. Results: Eight patients with a diagnosis of acute STEMI and duration of symptoms of <24 hours that were perfused successfully through primary percutaneous coronary intervention (PPCI) with a LVEF of <45% were assigned randomly to two groups (n = 4 each). One group treated with stem cells and the other corresponded to the control group. Neither death, re-infarction, no need for revascularization or thrombosis of the stent were observed at follow-up. Conclusions: The initial experience at the Instituto Nacional de Cardiología Ignacio Chávez in the treatment of acute STEMI by means of autologous transplantation of bone marrow-derived stem cells is encouraging. Implementation was possible in the first eight patients with no complications.

Objetivo: Describir el diseño y la implementación de un protocolo de transplante autólogo intracoronario de células madre derivadas de médula ósea en infarto agudo al miocardio con elevación del ST y reportar la seguridad del procedimiento en los primeros pacientes incluidos. Métodos: El estudio TRACIA se implementó con base en criterios de inclusión y exclusión predeterminados. El protocolo incluye la aleatorización, obtención de médula ósea, procesamiento de células madre, infusión intracoronaria de células madre, RM basal y al seguimiento, SPECT con ventriculografía radioisotópica basal y post-procedimiento, y seguimiento clínico a seis meses. Resultados: Ocho pacientes con diagnóstico de infarto agudo del miocardio con elevación del ST y duración de síntomas <24 horas que fueron reperfundidos exitosamente con angioplastia primaria y con fracción de expulsión <45%, fueron aleatorizados a dos grupos; uno de ellos fue tratado con células madre y el otro grupo permaneció como control. No se observó muerte, re-infarto, necesidad de revascularización o trombosis del Stent durante el seguimiento. Conclusiones: La experiencia inicial en el Instituto Nacional de Cardiología Ignacio Chávez en el tratamiento del infarto agudo del miocardio con elevación del ST mediante trasplante autólogo de células madre derivadas de médula ósea, es alentadora. La implementación sin complicaciones fue posible en los primeros ocho pacientes.

[The importance of multi-imaging diagnosis in cardiology]. / La importancia del diagnóstico multi-imagen en cardiología.

Cardiovascular imaging is one of the disciplines in cardiology with the most recent advances. This means that the teaching of Cardiology must evolve in the same way. In 2009, the American College of Cardiology published a statement, which points out that all of the cardiology residents must have basic training in every one of the cardiovascular imaging modalities available. Ischemic heart disease is the main cause of death in the world, including Mexico. Up to 43% of the patients that suffered a myocardial infarction and up to 31% of the patients with sudden cardiac death had an almost normal nuclear myocardial perfusion study in the year before the event, thus evidencing the importance of a multi-imaging approach. With the better understanding of the pathophysiological processes of coronary artery disease, new techniques have been developed that allows the detection of this disease almost from the beginning, through the detection of endothelial dysfunction by Positron Emission Tomography. Later on, when the patient develops diffuse atherosclerosis, we can rely on the use of de coronary calcium score and the detection of atherosclerotic plaques with coronary computed tomography angiography. To detect the presence of myocardial ischemia, two methods are widely used: echocardiography and nuclear medicine. Other options to identify myocardial ischemia are magnetic resonance imaging and computed tomography, due to the development of the "Dual Source" and "Flash" technologies. After an acute coronary event, cardiovascular imaging is useful for risk stratification and detection of myocardial viability, being the positron emission tomography the gold standard.