In patients with chronic atrial fibrillation and left ventricular systolic dysfunction, restoration of sinus rhythm confers substantial benefit.

STUDY OBJECTIVES: To evaluate the benefit of sinus rhythm (SR) restoration in patients with chronic controlled atrial fibrillation (AF) and left ventricular systolic dysfunction (LVSD). DESIGN: Prospective case-control study on the short-term outcome (6 to 9 months) of clinical and echocardiographic variables following attempted cardioversion. SETTING: Outpatient clinic of a university hospital. PATIENTS: Fifteen men and 5 women, ranging in age from 40 to 76 years, who had chronic controlled (mean [+/- SD] ventricular rate, 82 +/- 10 beats/min) AF and left ventricular fractional shortening (LVFS) of < 28% at baseline. Control was provided by retrospective paired echocardiographic examinations of six AF patients, plus the study cases with potentially unsuccessful cardioversion or early recurrence of AF. INTERVENTIONS: Attempt to restore SR with amiodarone or electrical countershock. MEASUREMENTS AND RESULTS: Conversion was attained in 17 patients, but AF recurred early in 4 patients, 3 of whom had proven ischemic LVSD. In the 13 patients with sustained SR, LVFS increased from 20 +/- 4% to 31 +/- 6% (p < 0.0001). In contrast, no changes were detected in the control group (n = 13). This improvement was paralleled by decreases in left ventricular (LV) end-diastolic dimension (from 55 +/- 7 to 51 +/- 6 mm; p = 0.014), LV mass (from 181 +/- 28 to 159 +/- 37 g; p = 0.015), and left atrial diameter (from 45 +/- 9 mm to 42 +/- 7; p = 0.003). A marked decrease in heart rate (from 82 +/- 9 to 64 +/- 5 beats/min; p < 0.0001) and a reduction in New York Heart Association functional class (from 2.3 +/- 0.9 to 1.2 +/- 0.4; p = 0.0007) also were observed in patients with sustained SR but not among subjects in the control group. CONCLUSIONS: Even when adequate control of the ventricular rate has been achieved, the LV function of patients with chronic AF greatly improves after restoration and maintenance of SR.

[Prosthetic valve thrombosis: which is the most appropriate initial therapy?]. / Trombosis valvular protésica: cuál es la terapia inicial más apropiada?

INTRODUCTION AND OBJECTIVES: This study aims to investigate what is the best initial therapy for patients with obstructive prosthetic valve thrombosis. METHODS: Data from 47 patients diagnosed with prosthetic valve thrombosis in two tertiary hospitals during an 8-years period were analyzed. RESULTS: The involved prostheses were in mitral position in 34 cases (2 biological valves), in aortic position in 12, and in double mitral and aortic position in one. The thrombosis was not obstructive in 12 patients. In the remaining 35 patients, the prosthetic obstruction was treated by heparin (n = 2), thrombolysis (n = 19), or direct surgery (n = 14). There was no mortality in the thrombolytic group, although 6 patients needed surgery before discharge because of an abnormal prosthetic residual gradient (n = 5) or a persisting abnormal disc valve motion (n = 1). Five out of 14 patients of direct surgery died, 2 before the planned operation could be performed. Thus, mortality rate, in an intention to treat analysis, was very favourable to thrombolytic therapy (p = 0.008); and this, despite the higher index of clinical severity (on a scale from 0 to 4) was superior in this group of thrombolyzed patients: 3.3 0.6 vs. 2.1 0.9 in those who underwent surgery; p < 0.0001. CONCLUSIONS: In terms of mortality rate, thrombolysis is a better alternative than direct surgery to fight against obstructive prosthetic valve thrombosis. Even if the result is suboptimal, it allows the performance of surgery in better clinical conditions and, thus, with minor risk.

[Guidelines of the Spanish Society of Cardiology on valve heart disease]. / Guías de práctica clínica de la Sociedad Española de Cardiología en valvulopatías.

Valvular heart diseases, which continue to be a major cause of morbidity and mortality world wide, have undergone radical changes since the first valve prostheses were implanted 40 years ago. These changes have been the result of both scientific progress and improved standard of living in developed countries. The availability of penicillin to treat streptococcal pharyngitis and less crowded living conditions have now made rheumatic fever uncommon in these countries. However, other forms of valve impairment have appeared over the past several years. The etiology of some of these valvular diseases remains obscure (e. g. myxomatous mitral valve); others, such as the senile type of calcific aortic valve stenosis, seem to be the price to be paid for the extension of life expectancy. With regard to diagnosis, echocardiography has constituted a formidable tool for visualizing anatomic valve changes, interpreting complex hemodynamic derangements, and evaluating repercussion on the left ventricle. In addition, the iteration of this non-invasive examination has allowed a much better understanding of the natural history of non-severe valvular disease and therefore of the precise timing for surgical intervention, without awaiting, in most cases, the appearance of advanced symptomatology. This has also been possible because of the great advances in cardiac surgery which can be summarised as: a) the improvement in extracorporeal circulation and myocardial preservation techniques; b) the greatly improved biologic and mechanic valve substitutes; c) the introduction of imaginative mitral valve repair procedures, and d) the use of intraoperative transesophageal echocardiography to assess the adequacy of valve repair. At the same time, percutaneous catheter balloon valvuloplasty has emerged as a valid alternative to mitral surgical commissurotomy for mitral stenosis. All these changes, and many more that can not be described in this brief summary, make a review of the management of patients with valve heart disease appropriate.

[The practical clinical guidelines of the Sociedad Española de Cardiología on coronary surgery]. / Guías de práctica clínica de la Sociedad Española de Cardiología en cirugía coronaria.

Surgery in coronary disease, including myocardial revascularization and the surgery of mechanical complications of acute myocardial infarction, has shown to improve the symptoms, quality of life and/or prognosis in certain groups of patients. The expected benefit in each patient depend on many well-known factors among which the appropriateness of the indication for surgery is fundamental. The objective of these guidelines is to review current indications for cardiac surgery in patients with coronary heart disease through an evaluation of the degree of evidence of effectiveness in the light of current knowledge (systematic review of bibliography) and expert opinion gathered from various reports. Indications and the degree of recommendation for conventional coronary artery bypass grafting have been established for each of the most frequent anatomo-clinical situations defined by clinical symptoms (stable angina, unstable angina and acute myocardial infarction) as well as by left ventricular function and extend of coronary disease. Furthermore, the subgroups with the greatest surgical risk and stratification models are described to aid the decision making process. Also we analyse the rational basis and indication for the new surgical techniques such as minimally invasive coronary surgery and total arterial revascularization. Finally, the indication and timing of surgery in patients with mechanical complications of acute myocardial infarction are considered.

Long-term results of the Spanish trial on treatment and survival of patients with predominantly mild heart failure.

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.

[The tilt-table test in assessing syncope of unknown origin: do differences exist between children and adults?]. / El test de basculación en la evaluación del síncope de origen desconocido: existen diferencias entre niños y adultos?

BACKGROUND AND OBJECTIVES: Little is known about the differences between children and adults in the results of head-up tilt test. This study sought to investigate the potential differences concerning: a) the clinical profile and circumstances of spontaneous syncope; b) the overall diagnostic performance of the test, and c) the type of positive response obtained. MATERIAL AND METHODS: We studied 31 children and 123 adults with unexplained syncope. If baseline test (tilting at 70 degrees for 30 min) resulted negative, it was repeated under isoprenaline low-dose infusion. RESULTS: There were no differences in either clinical profile, except for severe traumatism more frequent in adults (25% vs. 3% in children; p < 0.05), or overall diagnostic performance (39% in children vs. 33% in adults; p = NS). However, the way the test rendered positive (via basal tilting in 92% of children vs. 50% in adults; p < 0.05) and the rate of cardioinhibitory response (42% in children vs 8% in adults; p < 0.01) were significantly different. CONCLUSIONS: In this study children, in contrast to adults, rarely have a positive response in tilting under isoprenaline infusion. They also present a much higher rate of cardio-inhibitory response than adults.

[Is the exercise test performed after myocardial infarct really useful in improving prognosis? Arguments in favor]. / Es realmente útil la prueba de esfuerzo realizada después de un infarto de miocardio para mejorar el pronóstico de los pacientes? Argumentos a favor.

The evaluation of risk after myocardial infarction accomplishes two objectives: a) selecting patients with high-risk for coronary angiography and revascularization, and b) identifying low-risk patients to avoid unnecessary laboratory investigation and revascularization procedures. Currently, patients eligible for exercise test are those with no evidence of heart failure or angina, and with a preserved left ventricular function. Overall prognosis for such patients, especially if they were thrombolyzed, is very good. In this setting, in contrast to that pointed out in previous reports, the positive predictive value of exercise electrocardiography is very low (i.e., a patient with S-T depression has a probability of cardiac death in the ensuing year of only 4% vs 2% if the test is negative). This suggests that a routine postinfarction exercise test is inefficient from a prognostic point of view. However, a recent study has shown that thrombolyzed patients with a positive response to the exercise test, have a significantly lower rate of reinfarction and unstable angina when they undergo myocardial revascularization. Mortality rate, as it was low in the study population, was unchanged by the use of revascularization procedures. We conclude that, in spite of the limitations pointed out, there are at least two reasons to continue performing exercise tests in all uncomplicated infarctions: a) a negative test, due to its high negative predictive value for adverse events, reassures the patient and his family and prompts an early discharge, and b) some patients, despite an uncomplicated in-hospital evolution, have a "strong" positive response that suggests multivessel disease and a possible benefit from myocardial revascularization.

[Valve diseases in the aged: when to operate?]. / Valvulopatías en el anciano: cuándo operar?

Valvular lesions, especially aortic stenosis, are not uncommon among the elderly, a sector of the population that is increasing in relative (extreme decrease in birth rates) and absolute terms (reduction of morbidity/mortality due to health and social advances), and their treatment presents a major challenge to the health system. Advanced age constitutes a surgical risk, but this is more likely due to a greater prevalence of comorbid conditions than to an intrinsic effect of old age. Moreover, the morbid effects of age are extremely variable, and an individualized evaluation of the problem is required. The decision to surgically intervene in an elderly patient must take into account of three aspects: a) that the valvular lesion has important hemodynamic consequences; b) that the symptoms are a product of the lesion and not of a concomitant disease, and c) that there is no comorbid condition whose symptoms and prognosis are even worse than the valvular disease itself. The psychological attitude of patients and their family members is also a factor to be considered. In severe aortic stenosis, valve substitution normally has a highly effective palliative effect, although at the cost of a moderately increased surgical risk. In mitral stenosis, preference should be given when possible to valvuloplasty with a balloon catheter. In degenerative mitral regurgitation, reconstructive techniques and prosthetic substitution with chordal preservation have considerably improved surgical outcomes, so that surgery is now indicated earlier to avoid the development of irrecoverable ventricular dysfunction. In mitral regurgitation of ischemic origin, structural damage (rupture of papillary muscle) must be differentiated from functional damage (dysfunction of papillary muscle); in the former, surgery is normally mandatory with a favorable outcome; in the latter the issue is more complex, and the possibility of improving the regurgitation by angioplasty of the culprit vessel must be thoroughly explored. The valvular sequelae of infectious endocarditis, a disease with higher incidence in old age, receive the same treatment at younger ages. Finally, in autochthonous tricuspid regurgitation, which can appear years after successful left side heart surgery, the decision to intervene is more difficult; in most cases it may be an expression of right ventricular dysfunction and a conservative approach would be indicated.

Value of single oral loading dose of propafenone in converting recent-onset atrial fibrillation. Results of a randomized, double-blind, controlled study.

AIMS: To evaluate the efficacy and safety of a single loading oral dose of propafenone in the interruption of recent-onset atrial fibrillation. METHODS: After a complete medical history, physical examination, 12-lead ECG, chest X-ray, and routine biochemical laboratory testing, 55 consecutive patients with recent-onset atrial fibrillation were randomized double-blind in the emergency department for the administration of either a single oral dose (450 to 750 mg) of propafenone (29 cases) or a placebo (26 cases). After the 24-h observation period, comprehensive echocardiographic examination was performed. RESULTS: The groups were homogeneous as regards biological, clinical and echocardiographic characteristics. Two hours after treatment, 12 patients (41%) on propafenone but only two (8%) on placebo had converted to sinus rhythm (P = 0.005). This striking difference was maintained 6 h after treatment (65 vs 31%; P = 0.015) but lessened at 12 h (69% vs 42%; P = 0.060) and was insignificant at the end of the 24-h treatment period (79%, vs 73%; P = 0.752). Apart from hypotension, transient in three cases and sustained in one whose later echocardiographic examination demonstrated left systolic ventricular dysfunction, propafenone was well tolerated. CONCLUSION: Although there is no significant difference in the rates of conversion 24 h after treatment, propafenone works faster than placebo in achieving sinus rhythm. This rapid action of oral propafenone can be useful to solve quickly the clinical problems of a high proportion of patients arriving at the emergency department with acute atrial fibrillation.

[Usefulness of the angiographic examination of the left internal mammary artery in patients candidates for coronary bypass surgery]. / Utilidad del examen angiográfico de la arteria mamaria interna izquierda en pacientes candidatos a cirugía de derivación coronaria.

BACKGROUND AND OBJECTIVE: The usefulness of preoperative angiographic evaluation of the internal mammary artery (IMA) is controversial. The aim of this study is to evaluate the problem by a basic cost-benefit analysis. METHODS: One hundred and twenty-one patients whose coronary findings (left main disease and/or severe stenosis of the left anterior descending artery) made use of the IMA as a bypass graft a consideration were studied. The IMA was cannulated by the same right Judkins catheter used in the coronarography; the specific catheter was only used if the cannulation was not successful with the right Judkins. We measured the time it took for a good angiography of the IMA to be obtained; the anatomy and the size for each IMA were studied and compared with the size of the left anterior descending artery. RESULTS: An optimal angiographic picture of the IMA was obtained in 119 cases (98.3%); a specific catheter was used only in 3 patients. The mean of the time employed was 170 seconds (8-900 s) and no complications were related to IMA cannulations. Angiography findings relevant to any planned surgery were demonstrated in 15 patients (12%): large proximal branches (10); occlusion stenosis or a caliber insufficient for IMA (3); and occlusion or proximal subclavian stenosis (2). CONCLUSIONS: We have observed that the relation between the cost and the obtained information is adequate to warrant its performance, because angiographic findings relevant to planned surgery can be very important, even though they are fairly infrequent. Moreover, these findings can be achieved rapidly without additional cost.

The value of exercise electrocardiography testing in the identification of coronary restenosis: a probability analysis.

We studied by means of probability analysis the role of exercise ECG in identifying coronary restenosis. A total of 213 patients were independently evaluated by clinical history, conventional assessment of the exercise ECG ('yes or no' statement), D score (a discriminant function derived from exercise ECG), and coronariography, 5.4 +/- 2.8 months after successful coronary angioplasty. The initial probability of restenosis (30%), that is, the prevalence of the condition, was radically changed by the result of clinical history (77% for patients with angina vs. 17% for those without angina). By contrast, ECG binary assessment, due to its low accuracy (70% vs 82% of clinical history, P < 0.005), was unable to significantly change the established probabilities after symptomatic evaluation. Finally, D score, which greatly enhanced specificity (92% vs. 76% of bivariate assessment, P < 0.0001), proved to be useful in changing the probability (from 32% to 76% or to 25%) of patients (n = 34) with a discordant result (no angina/positive exercise ECG). When this stepwise approach was tested in 46 new patients, predicted and observed probabilities were actually very similar. We conclude that exercise ECG has a very limited role in identifying coronary restenosis if positive responses are not adjusted with a weighted score which takes into account other exercise derived factors.

[Probability analysis of the value of ergometry in the detection of restenosis after coronary angioplasty]. / Análisis probabilístico del valor de la ergometría en la detección de reestenosis tras angioplastia coronaria.

To evaluate the usefulness of treadmill exercise test in the diagnosis of coronary restenosis, we have chosen a sequential and probabilistic analysis. The rate of coronary restenosis found in the sample (n = 213) was of 30%. This initial probability of having restenosis was radically changed by the recurrence of typical angina: 77% in patients with this symptom, 17% in those without (p < 0.001). In contrast, the qualitative result of the exercise test was unable to change significantly the probabilities established after anamnesis. This was due to a lower specificity for exercise test (76%) than for angina (93%), the sensibility being the same (56%) for both. Employment of a discriminant value that integrates different ergometric variables did not enhanced sensibility, but allowed the identification of a good number of false positive results and therefore palliated the negative impact of faulty specificity. Being applied to a "discordant group" (no angina/positive exercise test, n = 34) was able to achieve a significant change in probability: from 15% to 50% or 4% (p < 0.01), according to the discriminant being lesser or greater than a preestablished value. In conclusion, prevalence of the event and evaluation of symptomatology are both important to estimate the probability of suffering coronary restenosis. On the contrary, exercise test, in the absence of a weighty method, adds more confusion than clarity to the analysis of the problem. Our results can be used to improve the follow-up of patients who have been successfully dilated by angioplasty.

Significant coronary restenosis limits the recovery of regional left myocardial dysfunction achieved after successful coronary angioplasty.

Impaired regional left ventricular function has been shown to improve after successful transluminal coronary angioplasty, but there are no data concerning the effect of coronary restenosis on this recovery. Therefore, the short- (1 month) and midterm (5.5 months) evolution of systolic regional left ventricular function was prospectively investigated in 41 patients undergoing successful coronary angioplasty. In patients with resting hypokinetic areas before angioplasty and no restenosis (n = 8), regional function improved from -6.0 +/- 2.9 to -2.9 +/- 2.4 SD/segment (P < 0.01) in the short-term, without further significant changes at mid-term. Patients with hypokinetic areas and coronary restenosis > or = 70% (n = 15) also showed early functional recovery from -5.1 +/- 2.2 to -1.4 +/- 2.5 SD/segment (P < 0.00001) but, in contrast with the other subset of patients, a significant reduction to -3.9 +/- 2.3 SD/segment (P < 0.0001) was observed at mid-term. In spite of this, regional function was still better than before angioplasty (P < 0.01). No significant changes were observed in patients without either asynergy or restenosis (n = 16). The small number of cases without preliminary hypokinesis and development of restenosis > or = 70% (n = 2) precluded an analysis of this situation, but a new and severe hypokinetic defect was recognized in one patient in a later study. We conclude that the improvement in regional myocardial function observed early after successful dilation of the culprit vessel is partially lost when significant restenosis develops.

[Double subvalvular aortic stenosis (fixed and dynamic) diagnosed by ECHO-Doppler]. / Doble estenosis subvalvular aórtica (fija y dinámica) diagnosticada con ECO-Doppler.

Fixed subvalvular aortic stenosis is an uncommon cause of left ventricular outflow obstruction which occasionally can be found in association with dynamic muscular obstruction. In the past, the diagnosis of this association has been difficult and relied upon cardiac catheterization and angiography. To our knowledge, no case of this pathology diagnosed by echo and Doppler has previously been reported. We present a case of double subvalvular aortic stenosis in a 35 years old patient which illustrates the feasibility of detection with echo and Doppler of both types of subvalvular aortic obstruction.

Success determining factors in percutaneous transluminal balloon valvuloplasty of pulmonary valve stenosis.

Twenty-two percutaneous transluminal balloon valvuloplasty procedures were performed on 21 patients with congenital pulmonary valve stenosis. The peak systolic pressure gradient was immediately reduced from 79.1 +/- 7.4 to 22.2 +/- 1.8 mmHg, (P less than 0.0001) and follow-up cardiac catheterization at 5.3 +/- 0.4 months in 19 patients revealed no further significant change in gradient (23.5 +/- 3.2 mmHg). The best results were obtained when balloons larger than the pulmonary annulus were used, i.e. an immediate residual transvalvular gradient of 22.0 +/- 2.2 mmHg with a balloon/annulus ratio greater than 1, as opposed to 44.2 +/- 5.4 with a balloon/annulus ratio = 1 (P less than 0.001). The angiographically determined cusp thickness of the stenotic pulmonary valves was significantly greater than that of the control group of 24 patients without pulmonary valve stenosis (1.21 +/- 0.09 vs 0.59 +/- 0.02 mmHg, P less than 0.00001). The relationship between this parameter and the residual transvalvular gradient at follow-up was found to be significant (r = 0.77, P less than 0.001). It is concluded that balloon size is a determinant factor in achieving good results with percutaneous balloon valvuloplasty although cusp thickness, a factor to which scant regard has hitherto been paid, also plays a significant role in the residual transvalvular gradient measured at follow-up.

[Aortic stenosis with left ventricular systolic dysfunction: a severe disease but with good surgical prognosis]. / Estenosis aórtica con disfunción sistólica ventricular izquierda: una enfermedad grave pero con buen pronóstico quirúrgico.

From our series of 72 patients with severe valvular aortic stenosis, we identified 19 showing features of left ventricular systolic disfunction (ventriculographic ejection fraction less than 55% and/or fractional shortening less than 30% at M-mode echocardiography). In these patients, we found a significant inverse correlation between the fractional shortening and the systolic wall stress (r = 0.79, p less than 0.001). Clinically, 18 of the 19 patients were in NYHA class III (n = 11) or IV (n = 5), and two died before they could be operated upon. The remaining 17 had their aortic valve replaced (coronary artery bypass surgery was simultaneously performed in 2 patients). After a mean follow-up of 18 months, all patients are alive and show substantial symptomatic improvement (15 patients in class I and 2 patients in class II). Cardiothoracic index was reduced (61 +/- 5% preoperatively versus 52 +/- 5% postoperatively), and fractional shortening changed from 21 +/- 5% to 30 +/- 5%. The latter remains under normal limits in two thirds of the patients. Our results lend support to the idea that the systolic left ventricular dysfunction in aortic stenosis is due to the increased afterload, rather than to an intrinsic contractility defect. This explains the great functional improvement after the reduction of the systolic wall stress achieved by surgery.

[Diverticulum of the right ventricle]. / Divertículo de ventrículo derecho.

We report the case of a 38-year-old woman who underwent cardiac catheterization because of cyanosis from birth. This study revealed a right ventricular cavity hypoplasia, an atrial septal defect, and a diverticulum originated from the free right ventricular wall. Ventricular diverticuli, especially those in the right ventricle, are very rare malformations, usually associated with other cardiac defects. The right ventricular diverticulum is generally non-symptomatic, diagnosed by chance, and does not usually require surgical treatment.

[Transluminal angioplasty for aortic coarctation in newborns and infants]. / Angioplastia transluminal en la coartación aórtica del recién nacido y lactante.

It has been done transluminal angioplastic with catheter balloon in 14 patients who are under 1 year of age and who are affected by aortic coarctation. For this study, they were divided in two groups. The first one was formed by newborn children whose transcoarctation gradient was 52 mm Hg in average. The second group was integrated by 9 newborn children whose transcoarctation gradient was 59 mm Hg. After this experience was done the gradient descended to 9 and 15 mm Hg respectively. Twenty four hours later, two months later and over two more months, there were follow-up of the clinical situation, the evolution of the pulse, differential arterial pressure and the need of surgery. Of the first group only one of the patients, who is now 2 years old, is in good clinical condition; the others needed to be surgically intervened. Of the second group 4 patients, all of whom were over 3 months old at the time of the angioplastic had positive results. The rest needed surgical intervention.