Myocardial infarction in patients with systemic lupus erythematosus with normal findings from coronary arteriography and without coronary vasculitis--case reports.

The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin M [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis.

A case of giant arteriovenous shunt in a renal carcinoma.

We present the case of a 51 year-old-white male with a giant right renal arteriovenous fistula secondary to a carcinoma. Neither the aorta nor the kidneys were visualized after the injection of 60 mL of contrast media into the abdominal aorta. Moreover, the right kidney could not be visualized after 30 mL of contrast media were injected selectively into the right renal artery. This was due to a great arteriovenous shunt through the right kidney. The right renal angiogram was obtained through digital imaging, after injecting contrast media into the right renal artery, previously occluded by a balloon-catheter. The image of an hypervascularized nephroma was obtained, depicting an important arteriovenous shunt of the contrast material toward the inferior vena cava from a fistula located in the right inferior renal pole. The occlusion of the right renal artery was partially achieved by injecting 40 mL of boiling contrast media, followed by small fragments of Gelfoam suspended in the contrast substance. The balloon-catheter remained inflated in the right renal artery until a nephrectomy was performed. As far as we know, a case in which the aorta and renal circulation are unable to be seen by means of conventional angiography, because of the presence of a renal arteriovenous shunt to the fistula, has not been described.

[Occlusion of interventricular septal rupture in 2 patients with an infarction]. / Oclusión de ruptura septal interventricular en dos pacientes con infarto.

We describe two women with interventricular septal rupture secondary to a myocardial infarction due to a total obstruction of the anterior descendent coronary artery. With the aim to stabilize the hemodynamic state of the patients before the surgical closure of the defect, we inserted a balloon-catheter introducing it to the left ventricle from the aorta and inflating it in the right ventricle after passing it through the septal orifice. After occlusion, we observed decreases in the pulmonary to systemic blood flow ratio (6% in one patient and 26% in the other) and in the arteriovenous blood flow shunt (8 and 31%); a 10% systemic blood flow increase was observed in one patient. Since the pulmonary arterial pressure did not change and the pulmonary blood flow increased, an increase of the pulmonary arterial resistance was observed but no modification of the pulmonary and systemic arterial pressure occurred. In the following days, the oxymetric differences between the pulmonary artery and the right atrium showed a tendency to remain below the figures before occlusion and the pulmonary blood flow and pressure showed a tendency to decrease. One patient died 14 days after the surgical closure of the rupture, and the other, seven days after the balloon occlusion of the rupture before any surgery. We present the physiological evolution of the patients.

[Asymptomatic ischemia in coronary arterial ectasia. Effects of anticoagulation]. / Isquemia asintomática en la ectasia arterial coronaria. Efecto de la anticoagulación.

We studied 23 patients (22 men and 1 woman), their ages ranged from 31 to 71 years (55.9 +/- 9.7 years), with isolated coronary arterial ectasia. Seventeen patients presented angina pectoris, 19 had myocardial infarction. An angiographic image of intracoronary thrombus was observed in 5 patients. Before the administration of anticoagulants (oral warfarin) 16 patients showed unstable angina, the exercise EKG was positive in 9 patients, and 16 patients presented silent ischemia (showed by EKG-Holter), whose duration was 35.21 +/- 29.27 min per day. After anticoagulants, only 5 patients showed unstable angina pectoris. Exercise EKG was positive in 7 patients and only 7 patients showed silent ischemia, whose duration decreased significantly (P < 0.001) to 12.47 +/- 22.5 min per day.

[Effectiveness of anticoagulant oral treatment in patients with thrombus in left ventricle after acute myocardial infarction]. / Eficacia del tratamiento anticoagulante oral en pacientes con trombo en ventrículo izquierdo después de un infarto agudo del miocardio.

Left ventricular mural thrombi (LVMT) is a complication of acute myocardial infarction (AMI), that may produce peripheral embolism which could be fatal. In order to establish an adequate time of oral anticoagulant (OA) therapy, we undertook a prospective study that included 45 patients with AMI and left ventricular thrombi detected by echocardiographic study, in the first 5 to 10 days postinfarction, the study was repeated, in 3 and 6 months. Treatment with oral anticoagulant was initiated at the point of the detection of thrombi maintaining an INR of 1.5 to 2. Thirty nine patients (79%) were males and 6 (11%) were females, with an age of 29 to 85 years and a range of 62 +/- 11 years. Forty four patients (98%) presented anterior wall infarction and 1 (2%) posteroinferior infarction. In patients with anterior infarction, in 38 (85%) the thrombi was located at the apical wall (p < 0.05), 5 (11%) in the septal wall and other (2%) in anterior and apical walls. The patient with the posteroinferior infarction presented extension to the right ventricle, where the thrombus was located (2%). The contractility alterations related with thrombi were diskinesia, followed by hipokinesia and finally akinesia. The ejection fraction had not relationship with thrombi formation. LVMT dissolved in 32 patients (71%) at 3 months (p < 0.05), in 8 (18%) in 6 months and in 5 (11%) it was maintained for more than 6 months. None of the patients presented complications of OA. We conclude that the LVMT are more frequent in anterior infarctions, essentially in those that present diskinesia. The majority of LVMT are resolved in 6 months with OA therapy.

A case of a coronary artery arising from the pulmonary artery.

We present a case of an anomalous origin of the left coronary artery arising from the pulmonary artery in a 60 year old woman with ventricular arrhythmias and ischemic electrocardiographic changes but who had tolerated eleven normal pregnancies and deliveries without complications. No cardiac surgical repair has been performed and she is asymptomatic and has been well controlled with diisopyramide during a ten year follow up.

[Identification and treatment of coronary atherosclerosis, before resection of abdominal aortic aneurysm]. / Reconocimiento y tratamiento de la enfermedad aterosclerosa coronaria, previos a la resección de aneurisma aortoabdominal.

Atherosclerotic aortic aneurysm, is frequently associated to coronary atherosclerosis. When myocardial ischemia is asymptomatic, aortic surgery commonly is deferred because unexpected ischemic cardiopathy. To diminish the risk of aortic surgery, aortocoronary bypass must be installed before the aortic graft. Percutaneous transluminal coronary angioplasty is an alternative treatment of coronary atherosclerosis, principally in elderly patients. We present the case of a male patient with an abdominal aortic aneurysm and myocardial silent ischemia secondary to right coronary artery stenosis treated by mean the percutaneous transluminal coronary angioplasty (PTCA) before aortic surgery, with the objective of decreasing surgical risk and its possible complications (myocardial infarction, cardiogenic shock, death, etc.). Nine months after the PTCA, the patient is asymptomatic and stress test on treadmill is negative.

[Cardiac rupture in acute myocardial infarct. Presentation of 20 postmortem cases]. / Ruptura cardiaca en el infarto agudo del miocardio. Presentación de 20 casos postmortem.

With the advancement of the Coronary Care Units in the past three decades, there had been an important reduction in mortality secondary to arrhythmias in acute myocardial infarction (AMI): been now days, cardiogenic shock and cardiac rupture the first and second causes of in-hospital death in these patients. The purpose of this report is to know the anatomoclinical characteristics in our hospital of cardiac rupture and to look for risk factors that may be considered to diagnose at the precise time this complication that might cause sudden death secondary to hemodynamic and electromechanical changes. From 300 postmortem cases with AMI proved clinical, and by anatomopathological studies, 20 cases with cardiac rupture were obtained, among which: 11 (55%) were males with an average age of 61.7 years and 9 (45%) females, with an average age of 60 years. The following coronary risk factors were detected: systemic hypertension in 15 (75%) cases; cigarette smoking in 13 (65%) cases and diabetes mellitus in 11 (55%) cases. Long lasting or recurrent history of chest pain previous to death was present in 14 (70%) cases. Conduction disturbances were detected in 13 (65%) cases; among them, 7 (35%) had third degree heart block in whom permanent pacemaker was inserted; 4 (20%) had CRBBB and 2 (10%) ASB. The average heart weight was 478 gr. in males and 434 gr. in females. Evidence of an old MI was present in 7 (35%) cases. All patients had transmural MI. Free cardiac wall rupture was seen in 14 (70%) cases and from the ventricular septum, 6 (30%) cases. Hemopericardium was present in all cases (100%) with an average amount of 425 ml of blood. Pericarditis in 3 (15%). The average time of evolution since the beginning of the AMI until death were 4 days and the main causes of death were cardiogenic shock in 17 (85%) and congestive heart failure in 3 (15%).

[Acute myocardial infarction with normal coronary arteries as initial manifestation of polyarteritis nodosa. A case report]. / Infarto agudo del miocardio con coronarias normales como primera manifestación de poliarteritis nudosa. Reporte de un caso.

A thirty four-year-old-white man in good health developed an acute anterior wall myocardial infarction (AMI), Killip II with normal coronary arteries. No thrombolytic therapy was given. Selective angiography revealed multiple aneurysms in mesenteric and renal arteries. The diagnosis of polyarteritis nodosa (PAN) was performed. AMI in PAN is secondary to arteritis with thrombosis, or to atherosclerosis due to steroid therapy. This case, having multiorgan vascular aneurysms involvement without previous cardiac symptomatology nor steroid therapy, presented as his first cardiac complication an AMI with normal coronary arteries probably due to selective arteritis.

[Limitation of myocardial expansion in late thrombolysis evaluated by two-dimensional echocardiography]. / Limitación de la expansión miocárdica con trombolisis tardía evaluada por ecocardiografía bidimensional.

Myocardial expansion in acute myocardial infarction (AMI) is present in about 45% of the patients within the first 72 hours. This is associated with ventricular aneurysm formation, myocardial rupture, heart failure and early death. Experimental studies in animals with AMI have used late reperfusion to decrease the incidence of expansion with success. The present is a prospective, longitudinal, open and randomized study in 21 patients with anterior AMI, to evaluate if the late reperfusion (6 to 12 hours) can decrease the incidence of myocardial expansion graded quantitatively with bidimensional echocardiography. Two groups were made: group A (n = 12) who received thrombolysis with streptokinase 1.5 mill. IU plus oral aspirin 150 mg OD (n = 9). Both groups had the same characteristics of AMI and functional class of Killip and Kimball (I-II class). Intrahospital treatment was given freely in both groups. The expansion was evaluated with bidimensional echocardiography used Jugdutt's method. In group A, expansion was present in 25% of the cases, while in group B was 66.6% (p < 0.0005). The distortion area, distortion peak, septal thickness and large asynergic segment were more sensitive parameters to identify myocardial expansion. Our results are similar to some experimental studies. We conclude that late thrombolysis can be useful in decreasing the incidence of myocardial expansion. Bidimensional echocardiography is a useful, fast and safe method to identify myocardial expansion.

[Transrectal recatheterization under echocardiography control]. / Recateterismo transeptal bajo control ecocardiográfico.

We present the case of a 36 years-old woman, in whom antegrade mitral intraluminal valvulotomy was performed under transesophageal echocardiography control. Inadvertently, we retired the Inoue's catheter to the right atrium from the left atrium, before the dilation of the mitral valve was accomplished. Under echocardiographic control we reintroduced the transseptal catheter across the former septal orifice, avoiding a new septal puncture, and its possible complications. Now a days, the antegrade intraluminal mitral valvulotomy is easy performed, because the transesophageal echocardiography monitoring. The transesophageal echocardiography has modified the transseptal catheterization contraindications.

[Percutaneous mitral commissurotomy using Inoue's balloon during pregnancy]. / Comisurotomía mitral percutánea con balón de Inoue durante el embarazo.

The authors present three cases of pregnant women with symptomatic severe mitral stenosis with a mean age of 28.6 +/- 2.3 years, and during 27.6 +/- 1.52 weeks of pregnancy. Two patients were in class III and one in class IV of the New York Heart Association (NYHA). All patients had a mitral valvular area equal or less than 1 cm2, with a Wilkins score of 7 to 9 and mitral insufficiency grade I in two cases; two, had severe pulmonary arterial hypertension (mean > 50 mm Hg). After Percutaneous Mitral Valvuloplasty (PMV) the mitral valve measured by 2D echocardiography increased form 0.83 +/- 0.2 cm2 to 1.8 +/- 0.15 cm2; the mean transmitral gradient diminished from 13 +/- 3.4 mm Hg to 3.6 +/- 1.15 mm Hg; the degree of mitral insufficiency was no modified in neither case. Hemodynamic results revealed increasing of the mitral valve from 0.83 +/- 0.18 cm2 to 2.23 +/- 0.3 cm2; the mean mitral gradient decreased from 21.6 +/- 9 to 4.3 +/- 0.5 mm Hg; the mean left atrial pressure from 30 +/- 12 to 12.3 +/- 4 mm Hg; the mean pressure of the pulmonary artery diminished suddenly from 44.3 +/- 16 to 25.6 +/- 11 mm Hg. The average fluoroscopic time was 15.3 +/- 3 minutes. There were no complications. The patients were discharged 48 hours after the procedure and continued their pregnancies in class I NYHA, which resolved in a non complicated vaginal delivery with normal products. We conclude that PMV is a safe and useful therapy in pregnant patient with severe mitral stenosis refractory to medical treatment.

[Indications for coronarography in heart valve diseases]. / Indicación de la coronariografía en las valvulopatías cardíacas.

Among 407 patients with rheumatic heart disease studied in our department, we found 8.3% with coronary atherosclerosis: 2.7% with mitral stenosis and 2.4% with aortic stenosis, lower figures than those reported in the literature. In our patients with coronary atherosclerosis, the male to female ratio was 1.6:1. The mean age of men and women with coronary atherosclerosis were 58.9 +/- 8.48 years and 60.33 +/- 5.75 years respectively. The cumulated relative frequency curve of the age was shifted to the right in the patients with coronary atherosclerosis, compared with the age frequency curve of the patients with normal coronary arteries: 50% of the cases with coronary atherosclerosis were < or = 60 years old; on the other hand, 50% of the patients with normal coronary arteries were < 53 years old. We only discovered 3 patients younger than 50 years old with coronary atherosclerosis. In order of frequency, the coronary arteries more affected were the anterior descending, right and circumflex. The mean coronary stenosis was 75.2 +/- 21.2%. Disease of one vessel was observed more frequently. We believe that age is not a good parameter to indicate coronarography in patients with valvular heart disease. If coronarography would be performed in all patients with valvular disease > or = 30 or 40 years old, would result in a great number of normal studies, with the consequent misspend of supplies and the increased risk of complications. On the other hand, restricting the coronarography indication, would miss the diagnosis in patients that might need myocardial revascularization. To restrict or to increase the indication of coronarography in patients with valvular disease will depend of the frequency between rheumatic heart disease and associated coronary atherosclerosis, and also on the atherosclerosis risk factors present in each patient. We recommend not to use the age of the patients as an index to indicate coronarography.

Case report of association of congenital coronary fistulae with coronary atherosclerosis.

The authors report the clinical case of a 70 year old male with a congenital plexiform fistula between a branch of the left coronary artery and the pulmonary artery, associated with the atherosclerotic lesions of the coronary arteries, both surgically treated by ligature of the fistula and aorto-coronary grafts. The patient remained asymptomatic up to the age of 65 when both cardiac ischemia and infarction ocurred, probably coincidental with the development of the coronary arterial obstruction. From data gathered from medical literature, the authors discuss the association between coronary congenital anomalies (fistulae and ectopies) with atherosclerotic obstruction of the coronary arteries. Coronary arterial atherosclerosis affects patients with congenital fistulae of the coronary arteries in the same way as in normal humans.

[The first myocardial infarct in the elderly patient]. / Primer infarto miocárdico en el anciano.

UNLABELLED: Acute myocardial infarction (AMI) in patients over 65 years of age represent more than half of the patients with AMI. Among them, between 60 and 80% represent the first AMI. The objective of this study is to evaluate the behavior of AMI in this group of patients. The clinical charts of patients over 65 years of age with ischemic heart disease admitted into the hospital during the past two years, were reviewed. We used the international criteria (clinical, ECG, enzymatic, echocardiographic and scintigraphic studies) for the diagnosis of AMI. Patients with previous AMI were excluded. We included 274 patients (68% males and 32% females). The age varied from 65 to 91 years with an average of 71.7 +/- 5.3 years. Typical symptoms were present in 90.5% and atypical in 9.5% of the cases, being the latest most frequent in those over 75 years of age. RISK FACTORS: cigarette smoking was present in 60% of the patients, hypertension in 52% and diabetes mellitus in 37%. Both of them were associated in 21%. In 144 cases (52.5%) the MI localization was anterior and in 130 (47.5%) inferior; among them 47 patients (36%) had extension to the right ventricle and 7 (2.5%) had a non Q AMI. COMPLICATIONS: Type I-II VPCs of Bernard Lown were present in 18% and type V 10.2%. Compete AV block in 14.2% (all of them with inferior wall MI); bifascicular block in 55 and mitral insufficiency due to papillary muscle dysfunction in 6.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

[The echo-dobutamine pharmacological stress test in ischemic cardiopathy]. / Prueba de estrés farmacológica eco-dobutamina en cardiopatia isquémica.

We report our experience with Echo-Dobutamine stress test. In order to evaluate the sensitivity, specificity and the safety, of the pharmacologic echo-dobutamine stress test, we studied 30 patients with ischemic heart disease based on clinical history, 2D echocardiogram, standard exercise stress test and cardiac catheterization. The test was started under continuous videotape of the segmental left ventricular motility on the conventional views. Dobutamine was administer intravenously 2.5 to 40 micrograms/kg/min every 3 minutes, the mean higher dobutamine dose was 19 +/- 14.3 micrograms/kg/min, having a continuous electrocardiographic monitoring of the heart rate as well as blood pressure. The myocardial motility was recorded with each increment in the dobutamine dose. Among the cases, 22 were males and 8 females with an average age of 55 +/- 9 years. Twenty two patients had history of remote myocardial infarction and were asymptomatic at the moment of the test; 8, who had angina pectoris were on a functional class I-II of the CCS. The mean basal ejection fraction was 62.6 +/- 11.7% by echo vs 64.4 +/- 16.8% obtained by cardiac catheterization (p no significant). There were no arrhythmias in any case. The heart rate increased from 68.7 +/- 10.1 to 85.5 +/- 15.7 beats per minute (p < 0.001). The systolic B/P was increased from a mean of 124 +/- 14.5 to 138.3 +/- 14.4 mmHg (p < 0.0005) while the diastolic pressure varied from 82.3 +/- 8.2 to 90.8 +/- 9.6 mmHg (p < 0.001). There were no severe complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Morphofunctional correlation in congenital anomalies of the coronary arteries. II. The ectopic origin of the coronary arteries]. / Correlación morfofuncional en las anomalías congénitas de las arterias coronarias. II. Origen ectópico de las arterias coronarias.

The authors describe the morphogenesis and functional alterations of the coronary arterial net in the ectopic coronary arteries: a) with origin in the aorta or its branches and b) with origin in the pulmonary artery. The coronary arteries are developed from: 1) endothelial sprouts localized in the great arteries walls at the level of the sigmoidal values, 2) right and left subepicardial vascular network and 3) the intramyocardial sinusoids. Most of the ectopic coronary arteries result from alterations in the connection between these three embryonic elements. The deviation of one of the subepicardial vascular network in a wrong way (in direction of pulmonary artery or the opposite Valsalva sinus) will stimulate the development of endothelial sprouts which will connect such network originating abnormal connections and anomalous origin of the coronary arteries. The origin of both coronary arteries from the pulmonary artery is in compatible with life. Myocardial ischemia is absent in patients with type I (infant) or type II (adult) anomalous origin of one coronary artery from the pulmonary artery, only in the transitional phase between both types (I and II) there is myocardial ischemia previous to the formation of the collateral coronary circulation. The ectopic origin of the coronary artery from the aortic Valsalva sinus have very little hemodynamic repercussion in the patient. Although there are cases with postexercise sudden dead. These anomalies associated to atherosclerotic coronary stenosis have an impact on the evolution and prognosis of ischemic heart disease.

[Calculation of the mitral valve area with the proximal convergent flow method with Doppler-color in patients with mitral stenosis]. / Cálculo del área valvular mitral con el método del flujo convergente proximal por eco Doppler-color en pacientes con estenosis mitral.

In this study we evaluate prospectively a new color Doppler method for calculating the mitral valve area based on identifying a blue-red aliasing interfase proximal to the orifice, corresponding to the flow convergence region (FCR). This method can be used to calculate areas using the continuity equation. We studied 61 patients with stenosis. The mitral valve area was calculated using pressure half-time (PHT) Doppler method which were compared with values that obtained by the FCR method, according to the following formula. AVM (cm2) = 2 pi r2 x VN/Vmax; where "r" is the FCR radius measured from the orifice to the first color aliasing (blue-red interface); VN is Nyquist velocity and Vmax is the peak flow velocity by continuous wave Doppler. Twenty three patients had pure mitral stenosis and 38 double mitral lesion. Twenty patients were on sinus rhythm while 41 in atrial fibrillation. Calculated mitral valve area using the FCR method correlated well with mitral valve area determined by PHT method at a correlation coefficient of r = 0.96 (y = 0.097 x + 54.9, SEE = 0.10 cm2, p < 0.001). MVA by FCR ranged from 0.4 to 2.5 cm2 (mean = 1.19 cm2). MVA by PHT ranged from 0.42 to 2.48 cm2 (mean = 1.15 cm2). Color Doppler FCR method provides an accurate estimate of effective mitral valve area and may be useful as an alternative to the pressure half-time method. The calculated mitral valve area by the FCR method is not influenced by the presence of mitral regurgitation nor atrial fibrillation.

[Morphofunctional correlation in congenital anomalies of the coronary arteries. I. Coronary artery fistulas]. / Correlación morfofuncional en las anomalías congenitas de las arterias coronarias. I. Fístulas arteriales coronarias.

In order to explain the congenital coronary arteries malformations, the authors review the recent concepts on the coronary artery morphogenesis, based in the findings that in the human embryo, these arteries evolve from three sources: 1) endothelial aortic buds, 2) cavitary cellular groups from pericardial origin and with angiogenic character, which migrate to the cardiac zones where the coronary arteries will be distributed, and 3) the intramyocardial sinusoids. The anatomic and histologic cardiac alterations will be reflected in modifications of the coronary artery pattern. The coronary artery fistulae are formed by the persistence of the sponge structure of the myocardial wall, present in the early ontogenic steps of the cardiac development; such fistulae alter the normal functions of the coronary vascular tree and are capable to cause angina pectoris to the patient through diverse mechanisms: absence of capillarization, steal phenomenon aggravated by the altered coronary arteries properties when aneurysm or vascular channels are developed. The authors suggest a classification of the congenital coronary arteries anomalies: I. Anomalous origin in the sinus of Valsalva (anomalous and ectopic origin), II. Malformations of the coronary branches (in number, distribution and wall anomalies) and III. Anomalous connection of the coronary arteries: fistulae and persistence of the intramyocardial sinusoids isolated or communicated to left and right ventricles. The latter are frequently associated with aortic or pulmonary valve atresia. They do not cause myocardial ischemia and are formed secondary to the intracavitary elevated pressure which maintained the persistence, dilatation and communication of the ventricular chambers with such sinusoids and coronary arteries in the case of pulmonary valve atresia and with coronary veins in the case of aortic valve atresia.