Implante de marcapaso definitivo en pacientes con vena cava superior izquierda persistente y ausencia de vena cava superior derecha: Caso clínico / Permanent pacemaker implantation in patients with persistent left superior vena cava and absent right superior vena cava: Report of three cases

Persistent left superior vena cava and absent right superior vena cava is an uncommon anatomical association. This is a challenging situation for permanent pacemaker implantation. We report three patients with this anomaly and a permanent pacemaker successfully implanted through the left superior vena cava and coronary sinus, without acute or chronic complications.

Experiencia de 36 años con marcapasos implantables: un análisis histórico / A 36 year experience with implantable pacemakers

Background: The implantation of pacemakers improves cardiac function and quality of life, in particular with dual chamber DDD and DDDR modes. Aim: To evaluate our clinical experience and results on pacemaker implantation, from 1963 to 1998. Material and methods: Computerized data collected from 2,445 consecutive paced patients was reviewed. A total of 3,554 operative procedures were performed, including 412 procedures for complications and 697 pacemaker replacement. Patient survival was determined from clinical records, inquiry to pacemaker manufacturers and death certificates from Servicio de Registro Civil e Identificaci-n de Chile (Chilean Civil and Identification Registry). Results: Use of dual chamber (DDD and DDDR) pacemakers increased progressively up to 74 percent from 1988 to 1998. Complication rate was 42 percent in the 1963-1976 study period, it decreased to 10.6 percent in the 1977-1987 study period, and to 5.6 percent by 1988-1998. Only two patients died during surgery in the study period (0.08 percent). In the 1977-1987 period, pacemakers lasted 10.6 years. Survival rates were 52 percent at ten years, 33 percent at 15 years, and 21 percent at 20 years, with a median survival of 11.7 years, and 7.24 years in patients over 80 years old. Conclusions: Transvenous permanent pacing can be accomplished today with a low complication rate, mainly due to better technology and surgical procedures

[Aortic valve multiple papillary fibroelastoma complicated with a cerebrovascular accident: Report of one case]. / Fibroelastoma papilar múltiple de válvula aórtica complicado de accidente vascular encefálico embólico. Caso clínico.

The echocardiographic identification of cardiac tumors as cause of embolic episodes is infrequent, and the finding of multiple papillary fibroelastoma is even less common. We report a 70 years old female with a history of a rheumatic mitral valve lesion, subjected to a commissurotomy in 1970. She was admitted with a cerebrovascular accident and the transesophageal echocardiogram revealed the presence of a multiple papillary fibroelastoma in the aortic valve. The patient was operated and the tumor excised, the pathological analysis confirmed the diagnosis. The patient was discharged in good conditions and after 8 months of follow up, she has no neurological abnormality and is in functional class I.

[Selective training of respiratory muscles in patients with chronic heart failure]. / Entrenamiento selectivo de los músculos respiratorios en pacientes con insuficiencia cardíaca crónica.

BACKGROUND: Patients with chronic heart failure have a lower inspiratory muscle strength and fatigue endurance. AIM: To assess the effects of selective training of respiratory muscles in patients with heart failure. PATIENTS AND METHODS: Twenty patients with stable chronic heart failure, aged 58.3 +/- 3 years with an ejection fraction of 28 +/- 9%, were subjected to respiratory muscle training with threshold valves. The load was fixed in 30% of maximal inspiratory pressure (PImax) in 11 and in 10% of PImax in nine. Two sessions of 15 minutes, 6 days per week, during 6 weeks were done. Degree of dyspnea (Mahler score), maximal oxygen uptake, distance walked in 6 minutes, respiratory muscle function and left ventricular ejection fraction were measured before and after training. RESULTS: Both training loads were associated to an improvement in dyspnea (+2.7 +/- 1.8 and +2.8 +/- 1.8 score points with 30% PImax and 10% PImax respectively), maximal oxygen uptake (from 19 +/- 3 to 21.6 +/- 5 and from 16 +/- 5 to 18.6 +/- 7 ml/kg/min with 30% PImax and 10% PImax respectively, p < 0.05), PImax (from 78 +/- 22 to 99 +/- 22 and from 72 +/- 34 to 82.3 cm H20 with 30% PImax and 10% PImax respectively), sustained PImax (from 63 +/- 18 to 90 +/- 22 and from 58 +/- 3 to 69 +/- 3 cm H20 with 30% PImax and 10% PImax respectively), and maximal sustained load (from 120 +/- 67 to 195 +/- 47 and from 139 +/- 120 to 192 +/- 154 g with 30% PImax and 10% PImax respectively). The distance walked in 6 min only increased in subjects trained at 30% PImax (from 451 +/- 78 to 486 +/- 68 m). CONCLUSIONS: Selective training of respiratory muscles results in a functional improvement of patients with chronic heart failure.

Periodontitis y enfermedad cardiovascular ateroesclerótica / Periodontitis and atherosclerotic cardivascular disease

Los factores de riesgo tradicionales como la hipertensión, dislipidemia, diabetes, tabaquismo, etc., no explican la etiología y patogénesis de las complicaciones de la aterosclerosis en todos los pacientes, motivo por el cual la etiología infecciosa de esta patología ha recibido gran atención últimamente. La periodontitis, infección crónica producida por bacterias Gram (-), se ha relacionado con las enfermedades cardiovasculares ateroscleróticas. Ambas patologías comparten factores de riesgo y mecanismos patogénicos que explicarían la posible asociación entre ellas. La presencia de un gran reservorio de bacterias y mediadores inflamatorios relacionados con la periodontitis, son los posibles mecanismos biológicos que relacionan ambas patologías, y la base para la hipótesis de que la periodontitis es un posible factor de riesgo para las enfermedades cardiovasculares ateroscleróticas

[Infective endocarditis: short and long-term results in 261 cases managed by a multidisciplinary approach]. / Endocarditis infecciosa: análisis de 261 casos y resultados del tratamiento con un enfoque multidisciplinario.

BACKGROUND: Early diagnosis, an effective treatment and prompt recognition of complications are essential to improve the prognosis of infective endocarditis (IE). AIM: To report the results of a multidisciplinary approach to diagnosis and management of patients with IE at the Universidad Católica de Chile Hospital. PATIENTS AND METHODS: The clinical history, diagnosis, treatment and outcome of 261 episodes (Duke criteria) of IE admitted between January 1980 and January 1999 were analyzed. These included 185 episodes of native, 73 of prosthetic valve and 3 of nonvalvular IE. RESULTS: Sixty nine percent of patients were men and the mean age was 49 +/- 16 years. Seventy five percent had a definite diagnosis of IE (Duke). S. viridans, staphylococci and enterococci together constituted 85% of the isolated bacterial strains. Twenty seven had culture-negative IE, related to a high incidence of antibiotic therapy prior to diagnosis. Transesophageal echocardiography was performed in 102 cases and it detected vegetations in 91% of aortic and 96% of mitral IE, rupture or prosthesis dehiscence in 67% of aortic and 52% of mitral IE and abscesses in 51% of aortic and 15% of mitral IE. Fifty one percent developed heart failure and 34% had embolic events. S. aureus IE was associated to a higher incidence of embolic events, complications which contraindicated surgery and increased mortality rate (27%). Of all patients, 40% were treated exclusively with antibiotics, 52% were operated on and 8% had surgical indication but were nonoperable because of serious complications. The overall mortality was 16.3%: 13% in the medical, 9% in the surgical and 81% in the non-operable groups. The type of treatment and mortality rates did not differ between IE of native valves and prosthetic valves. Long term follow up showed survival rates of 73% at 5 years and 66% at 10 years. CONCLUSION: A multidisciplinary approach may be very helpful to improve the prognosis of IE.

[Use of dual-chamber pacemaker. Short and long-term results]. / Marcapasos bicamerales. Resultados inmediatos y alejados.

BACKGROUND: Continuous improvement of dual chamber DDD pacemakers, electrode stability and programmed sequential stimulation changed the prognosis of patients implanted with these devices. AIM: To report our experience with the use of dual chamber pacemakers. MATERIAL AND METHODS: One hundred seventy six patients (116 male), aged 13 to 91 years old, who received a dual chamber pacemaker implant, are reported. Patients were followed for a mean of 2.6 years. RESULTS: Indications for DDD pacemaker were complete atrioventricular block in 43%, sick sinus syndrome in 32%, paroxysmal A-V block in 24%. All pacemakers were Siemens-Pacesetter and were provided with an automatic sensing and threshold device. J shaped atrium electrodes were used in 78% of patients and screw-in electrodes in 22%. Post operative complications were displacement of atrial electrode in 8 patients, of ventricular electrode in 6 patients, infection in two patients and a hematoma in one. Chronic parameters, measured after six months, were within expected ranges and allowed a good reprogramming of pacemakers. Long term programming aimed to reduce battery depletion, enhance device performance and improve hemodynamic conditions. Normal sequential stimulation was achieved in 154 patients (87%), 14 (85) patients died of cardiovascular disease not related to pacemaker function. Eight patients were in atrial fibrillation and were reprogrammed to VVI and DDI modes. CONCLUSIONS: DDD pacemakers are reliable and afford symptomatic relief in a broad spectrum of patients.

[Head-up tilt test in healthy asymptomatic patients]. / Tilt test en sujetos sanos asintomáticos.

The head-up tilt test has demonstrated to be useful in the study of patients with syncope of unknown origin for the diagnosis of neurocardiogenic syncope. Several publications have described different methods, with different results in cases as well as in controls. We performed a prospective study in a group of normal subjects in order to evaluate the methodology used in our population and to establish its specificity. A positive test was defined as the presence of syncope or presyncope and hypotension. The examination was carried out on a tilt table, five minutes at 0 degree, then at 70 degrees during 20 min. In the absence of syncope or presyncope an i.v. infusion of isoproterenol was started afterwards in order to increase the heart rate 30-50% over the baseline values and administered during 20 min at 70 degrees. Twenty one volunteers (14 male and 7 women; mean age 26.7 +/- 3.5 years; range: 21-33 years) and body mass index 23.4 +/- 2.2 kg/m2 were examined. Mean dose of isoproterenol was 3.1 +/- 0.9 micrograms/min (3.4 +/- 1.1 in men and 2.6 +/- 0.7 micrograms/min in women, NS). During the phase without isoproterenol no subject developed hemodynamic alterations neither symptoms. One volunteer (4.8%) developed presyncope and systemic hypotension (52/28 mm Hg) accompanied with nodal rhythm after 14 min of isoproterenol at 70 degrees, and his examination was discontinued, with immediate recovery. Three other subjects developed asymptomatic transient nodal rhythm during the phase with isoproterenol and recovered spontaneously. No other complications were observed. It is concluded that head-up tilt test with isoproterenol at 70 degrees, with the used doses and heart rate increments, is highly specific (95%) to establish the diagnosis of a neurocardiogenic syncope.

[Non-invasive intermittent mechanical ventilation: usefulness in treatment of chronic severe heart failure]. / Ventilación mecánica no invasiva intermitente: utilidad en el tratamiento de la insuficiencia cardíaca crónica avanzada.

BACKGROUND: The higher respiratory work and less inspiratory muscle strength of patients with cardiac failure may contribute to decrease their functional capacity. AIM: To assess the effects of non invasive intermittent mechanical ventilation on clinical parameters, peripheral perfusion, cardiac and inspiratory muscle function. PATIENTS AND METHODS: Patients with chronic cardiac failure, functional capacity III-IV were subjected to 6 sessions of nasal non invasive intermittent ventilation during 4 hours or to simulated ventilation (controls). RESULTS: Fifteen ventilated patients and six controls completed the protocol. Ventilated patients improved the Mahler transition score for dyspnea by 4 +/- 1.6 points. They also improved their aerobic capacity, increasing the exercise duration from 10.9 +/- 4 to 12.7 +/- 5 min and their maximal oxygen consumption from 14.6 +/- 4 to 16.4 +/- 5.7 ml/kg/min. These patients also decreased their O2 and CO2 ventilatory equivalents. Maximal inspiratory pressure increased from 67.9 +/- 23.6 to 80.19 +/- 21.4 cm H2O, sustained maximal inspiratory pressure increased from 101.4 +/- 48 to 133 +/- 53 cm H2O and maximal endurance increased from 132 +/- 52 to 162 +/- 58 g in ventilated patients. None of these variables was modified in control patients. No changes were observed in renal function, blood volume, arterial gases, spirometry or plasma catecholamine levels in any group. CONCLUSIONS: Intermittent nasal ventilation or other measures to improve inspiratory muscle function may be beneficial for patients with severe cardiac failure.

[Hospital course of acute myocardial infarction: significance of the therapeutic procedures of early reperfusion]. / Evolución intrahospitalaria del infarto agudo del miocardio: importancia de las medidas terapéuticas de reperfusión precoz.

Reperfusion therapy has contributed to decreased morbidity and mortality in patients with acute myocardial infarction (AMI). Implementation of thrombolytic therapy; primary angioplasty and emergency coronary artery by-pass surgery have proved to be effective in well designed controlled clinical trials. There is little information, however, about the impact of reperfusion therapy in the general clinical population that is usually seen in the coronary care unit. In this paper we have compared the clinical course, morbidity and mortality of patients attended for a first AMI in 2 different periods. Group I comprised 431 patients seen during the period 1981-1986 and group II bad 113 patients seen during the period 1992-1993. Age, gender distribution and AMI location were similar in both groups. Patients in group I had a significantly higher incidence of tobacco use and previous angina pectoris. In group I, 4% of patients received streptokinase, 0.9% of patients had emergency by-pass surgery and none had primary angioplasty, whereas in group II, 29% of patients received trombolytics, 6.5% had primary angioplasty and 6.5% had by-pass surgery. Heart failure Killip class II-III occurred in 35% of patients in group I and in 13% of patients in group II (p < 0.05). Intrahospital mortality was 19.6% in group I and 11.5% in Group II (p < 0.045). There were no differences in the incidence of cardiogenic shock in both groups. Multivariate analysis showed that age and heart failure were significant independent predictors of mortality in both periods. Thus, there has been a significant change in the therapeutic approach to AMI patients in recent years. Widespread utilization of reperfusion therapy appears to be associated with decrease in morbidity and mortality in a general population of patients with a first AMI.

[Cardiopulmonary exercise test in patients with chronic cardiac failure: comparison with normal subjects and reproducibility of measurements]. / Prueba de esfuerzo cardiopulmonar en pacientes con insuficiencia cardíaca crónica: comparación con sujetos normales y reproducibilidad de las mediciones.

The aim of this work was to measure oxygen consumption and carbon dioxide production during exercise in 21 subjects with cardiac failure and 13 normal subjects. During the resting period, subjects with cardiac failure had higher ventilatory frequency and respiratory quotient than normals. During maximal exercise, the former achieved higher ventilatory frequency and oxygen ventilatory equivalent than normals. In subjects with cardiac failure and normals, anaerobic thresholds were 14.4 +/- 0.9 and 28.8 +/- 2.2 ml/kg/min respectively and peak oxygen consumptions 17.1 +/- 1 and 34.4 +/- 1.7 ml/kg/min respectively. There were less than 10% differences in parameters when tests were repeated in 10 subjects with cardiac failure. It is concluded that gas exchange testing may be a reliable and objective assessment method in patients with cardiac failure.

[Cardiovascular response to exercise at high altitude in workers chronically exposed to intermittent hypobaric hypoxia]. / Respuesta cardiovascular al ejercicio a gran altura en trabajadores crónicamente expuestos a hipoxia hipobárica intermitente.

The isotonic work performance was assessed in 34 workers aged 35 +/- 5.8 years old that had working shifts of four days at 4500 m over the sea level and resting periods of other four days at the sea level during at least two years. Subjects were assessed in one occasion at the sea level, and at the first and fourth day of the working shift at 4500 m over the sea level. Resting arterial oxygen saturation in these three periods was 97 +/- 1.1, 88 +/- 18 and 91 +/- 1.1% respectively (p < 0.01), and markedly decreased during maximal and submaximal exercise at 4500 m over the sea level. Exercise duration in the three periods was 931 +/- 210, 775 +/- 105 and 778 +/- 105 seg respectively (p < 0.001). Heart rate in the resting period was at least 10% higher and maximal and submaximal rates were lower at high altitude. No differences in blood pressure or packed red cell volume were observed. Exercise duration correlated inversely with age (r = -0.49 p = 0.03) and directly with maximal heart rate (r = 0.44 p = 0.009) at the sea level. No correlation between aerobic capacity and other measured parameters was observed. These results show no differences in the cardiovascular response to exercise between the first and fourth day of stay at high altitude in workers chronically exposed to intermittent hypobaric hypoxia.

[Tilt test: hemodynamic responses in patients with syncope or presyncope of unknown etiology]. / Prueba de inclinación (tilt test): respuestas hemodinámicas en pacientes con síncope o presíncope de etiología no precisada.

The aim of this work was to assess the hemodynamic responses to the tilt test of 51 patients with syncope (n = 31) or presyncope (n = 20) of unknown etiology. A protocol with an inclination of 70 degrees (20 min) with or without isoproterenol (mean dose of 3.6 +/- 0.3 ug/min), was used. Forty five percent of patients had a positive test, 18 with isoproterenol at 70 degrees (group 1A) and 5 without isoproterenol (group 1B); 28 patients had a negative test (group 2). These groups did not differ in age or sex distribution. Basal heart rate was 76.2 +/- 2x'. At the end of the test it was 73.4 +/- 5.7 in group 1A, 78.0 +/- 7.5 in group 1B and 120.4 +/- 3.3 in group 2 (p < 0.01). Systolic blood pressure decreased to 78.1 +/- 4.8 mmHg in group 1A, to 76.2 +/- 9.9 in group 1B and did not decrease in group B (130.0 +/- 5.7 mmHg, p < 0.01). The required dose of isoproterenol was higher in group 1A than in group 2 (4.4 +/- 0.3 vs 3.1 +/- ug/min, p < 0.01). It is concluded that the tilt test reproduced symptoms and accompanying hemodynamic mechanisms in a high proportion of patients with syncope of unknown etiology. This test should be incorporated in the diagnostic workup of these patients.

[Characteristics of acute myocardial infarction in patients with diabetes mellitus]. / Caracteristicas del infarto agudo del miocardio en pacientes con diabetes mellitus.

We analyzed retrospectively the clinical course and prognosis of 565 consecutive patients with acute myocardial infarction (AMI), 117 of them with a previous history of diabetes mellitus. Male/female ration was 7.9/2.1 in non diabetics and 7.0/3.0 in diabetics (p < 0.03). Incidence of hypertension and hyperlipidemia was higher in diabetic patients as well as history of congestive heart failure (13.7% vs 6.5 in non diabetics p < 0.01). The type and location of AMI did not differ among groups, however the incidence of congestive heart failure Killip class III-IV was higher in diabetic patients (31.6 vs 21.2%). Peak CPK values were lower in diabetics (1.270 +/- 1.179 vs 1.648 +/- 1.377 U/l p < 0.01). Cardiac mortality was higher one month and one year after AMI in diabetics (17.1 vs 13.6% and 21.4 vs 17.8% respectively, p < 0.01). Univeriate and multivariate analysis identified new bundle branch block, heart failure and advanced age as independent predictors of mortality in both groups of patients. It is concluded that the worst prognosis of diabetic patients with AMI may be related to a previously depressed ventricular function and that appropriate metabolic control and treatment of associated risk factors, could improve the prognosis of diabetics patients with AMI.

[Evaluation of the effect of enalapril, a converting enzyme inhibitor, on lymphocytic beta-adrenergic receptors of patients with chronic cardiac insufficiency]. / Evaluación del efecto de enalapril, inhibidor de la enzima conversiva, en los receptores betaadrenérgicos de linfocitos de pacientes con insuficiencia cardíaca crónica.

We have previously corroborated that lymphocyte beta-adrenergic receptor density is significantly reduced in patients with chronic heart failure. It is well known that angiotensin converting enzyme inhibitors normalize the function of sympathetic nervous system. We have assessed the effect of enalapril on lymphocyte beta-adrenergic receptor system from patients with chronic heart failure (n = 14) using a random, cross and double blind protocol. Our results show that the improvement in clinical score and ventricular function were not related with changes in the number and affinity of beta-adrenergic receptor nor cyclic AMP content in lymphocytes obtained from these patients.

[Arrhythmogenic dysplasia of the right ventricle: clinical presentation and long-term course]. / Displasia arritmogénica del ventrículo derecho: presentación clínica y evolución alejada.

The clinical findings and follow up in 10 patients with arrhythmogenic dysplasia of the right ventricle were analyzed. Presentation occurred at a mean age of 35 +/- 12(SD) years and all patients presented with ventricular tachycardia and a left bundle branch block pattern. Physical examination was normal. T waves were inverted in right precordial leads in all and late depolarization were seen in 7. Global or segmental dilatation of the right ventricle was shown by echocardiogram in all patients and by right ventricular angiography in 8. After a mean follow up of 6.6 years (+/- 3), 70% had recurrence of ventricular tachycardia in spite of adequate antiarrhythmic therapy. Mortality was only 10%. Surgery was performed in 4 patients. Two patients had focal right ventricular fibrosis and resection lead to cure of arrhythmia.

[Risk of chronic oral anticoagulant treatment in elderly patients]. / Riesgo del tratamiento anticoagulante oral crónico en pacientes de mayor edad.

To assess age-related risks of long term anticoagulation, the records of 348 patients followed up at our university hospital outpatient anticoagulation clinic during a seven year period were reviewed. There were 129 patients, under 56 years of age, 144 from 56 to 69 and 75 over 70 years old. The total observation period was 1089 patient-years (3.3 yrs per pt). 64% of the patients had adequate anticoagulation level (prothrombin time < 35%, INR 2.2-4.5) 70 to 100% of the observation period. Prothrombin time was slightly, but significantly higher in the elderly group. During this period 21 patients developed major bleeding complications (1.84/100 pt yrs), 8 of them with fatal intracranial hemorrhages, and 20 embolic complications (1.93/100 pt yrs), 3 of them fatal. No significant differences in the incidence of both bleeding and embolic complications were observed in the three groups. The results of this retrospective follow-up study suggest that long term anticoagulation can be carried out in elderly pts with risk of hemorrhagic and embolic complications similar to those observed in the general population.

[Radiofrequency fulguration in patients with reciprocating tachycardias]. / Fulguración con radiofrecuencia en pacientes con taquicardias reciprocantes.

The use of radiofrequency for catheter ablation of accessory pathways and dual AV nodal pathways has been recently introduced. In this paper the results obtained in 5 patients are reported. Three patients had accessory pathways and 2 a dual AV nodal pathway. After a complete electrophysiologic study, a 7F Door Knob catheter coupled to a Radionics radiofrequency generator delivering a maximum of 16 watt at 480 KH was used to ablate the abnormal pathway. Success was obtained in every patient at times varying from 30 sec to 3 min, using 3 to 17 energy deliveries. These results include the first successful ablation of a left lateral bundle with radiofrequency using an energy of only 16 Watt.

[Sudden unexpected nocturnal death: report of a case and review of the literature]. / Muerte súbita nocturna inesperada: descripción de un caso y revisión de la literatura.

Sudden death usually affects individuals with severe heart disease. A more dramatic phenomenon is the sudden unexpected death of individuals with no evidence of heart disease. It has been described mainly in young healthy males under severe stress. We present a 32 year old man who presented ventricular fibrillation during sleep and was resuscitated by his wife. Recurrent episodes of VF occurred in the following hours. The study, including coronary angiography, revealed a normal heart. Endomyocardial biopsy showed minimal alterations with scarce areas of atrophy and fibrosis. Electrophysiologic evaluation showed an extremely short refractory period of the right ventricle, but the arrhythmia could not be induced by electrical stimulation. An internal cardioverter defibrillator was implanted since the risk of recurrent VF was high. A review of the literature concerning this unusual entity is offered.