Nuevo signo de la repolarización ventricular en el plano frontal para predecir disfunción sistólica ventricular izquierda / Novel sign of frontal plane ventricular repolarization to predict left ventricular systolic dysfunction

RESUMEN Objetivo: Distintas alteraciones del electrocardiograma (ECG) han sido asociadas a disfunción sistólica ventricular izquierda (DSVI), si bien la asociación con el infradesnivel del segmento ST (IST) del plano frontal del ECG estándar no se encuentra establecida. El objetivo del presente trabajo fue evaluar si el IST de la derivación DI (IST-1) permite predecir la presencia de DSVI. Material y métodos: Se incluyeron de forma prospectiva pacientes portadores factores de riesgo o cardiopatías crónicas estables, con ECG basal y ecocardiograma que aportara evaluación de la fracción de eyección (FEVI), motilidad ventricular izquierda y evaluación dicotómica sobre la presencia de hipertrofia ventricular izquierda (HVI). Evaluamos la morfología del segmento ST en derivaciones DI y V6, definiéndose como anormal (IST-1; IST-6) al ST infradesnivelado (≥1mm a 80mseg del punto J) o descendente. Resultados: Se analizaron en forma prospectiva 691 pacientes, edad media 69,8 ± 12 años, 61,6% hombres. Se identificó IST-1 e IST-6 en 250 (36,2%) y 199 (28,8%) casos, respectivamente. La presencia de IST-1 e IST-6 se asoció a una FEVI significativamente menor comparado con la ausencia de dicho hallazgo: 44,8 ± 13,9% vs. 55,6 ± 8,9%, (p <0,0001) y 45,8 ± 14,1% vs. 54,1 ± 10,4% (p <0,0001) respectivamente. Ambos se asociaron a la presencia de DSVI, definida como FEVI <50%, aunque el IST-1 mostró mejor rendimiento diagnóstico que el IST-6 [área bajo la curva 0,72 (IC 95% 0,69-0,76) vs. 0,64 (IC 95% 0,610,68), p = 0,0001]. Conclusiones: Este estudio mostró que la depresión del segmento ST de la derivación DI permite predecir la presencia de DSVI mejor que IST-6. La potencial relevancia de dichos hallazgos debería situarse en el contexto actual de la emergente utilización de dispositivos wearables que analizan la información electrocardiográfica mediante una única derivación.

ABSTRACT Background: Different electrocardiographic abnormalities have been associated with left ventricular systolic dysfunction (LVSD), although the association with standard electrocardiographic frontal plane ST-segment depression (STD) has not been established. Objective: The aim of this study was to evaluate whether lead I STD (STD-I) allows predicting the presence of LVSD. Methods: Patients with risk factors or stable chronic heart disease, and baseline electrocardiogram (ECG) and echocardiogram that provided evaluation of left ventricular ejection fraction (LVEF), left ventricular wall motility, and dichotomous evaluation of left ventricular hypertrophy (LVH), were prospectively included in the study. ST-segment morphology in leads I and V6 was evaluated, defining horizontal (≥1mm at 80 ms from the J point) or downsloping STD as abnormal STD-I and STD-6. Results: A total of 691 patients; with mean age of 69.8 ± 12 years and 61.6% men, were prospectively analyzed. STD-I and STD-6 were identified in 250 (36.2%) and 199 (28.8%) cases, respectively. Presence of STD-I and STD-6 was associated with a significantly lower LVEF compared with the absence of this finding: 44.8 ± 13.9% vs. 55.6 ± 8.9% (p <0.0001) and 45.8 ± 14.1% vs. 54.1±10.4% (p <0.0001), respectively. Both were associated with the presence of LVSD, defined as LVEF <50%, although STD-I showed better diagnostic performance than STD-6 [area under the ROC curve 0.72 (95% CI 0.69-0.76) vs. 0.64 (95% CI 0.61-0.68), p = 0.0001]. Conclusions: This study showed that STD-I predicts the presence of LVSD better than STD-6. The potential relevance of these findings should be placed in the current context of the emerging use of wearable devices that analyze electrocardiographic information through a single lead.

Evaluación del score de calcio coronario y valvular aórtico mediante TC de tórax no gatillada de baja dosis / Coronary and aortic valve calcium score assessment using low-dose non-gated chest CT

RESUMEN Introducción: El score de calcio coronario (SCC) es una herramienta de prevención subutilizada, en parte debido a su elevado costo, que no debería diferir del de una tomografía computarizada (TC) de tórax. El SCC puede ser evaluado mediante una TC de tórax convencional, generalmente utilizando escalas visuales o semicuantitativas, y con valor pronóstico similar al gatillado. Material y métodos: En este estudio observacional retrospectivo, incluimos pacientes (n = 35) en quienes se realizó dentro de la misma internación una TC de tórax no gatillada de baja dosis y un SCC gatillado. Resultados: Identificamos una buena concordancia entre los métodos tanto en su valoración cualitativa como cuantitativa, con una media de 3,86 ± 0,7 segmentos con calcificaciones arteriales coronarias mediante SCC gatillado, comparado con 3,79 ± 0,6 segmentos mediante TC de tórax no gatillada de baja dosis (coeficiente de correlación de concordancia 0,98 [IC 95% 0,95-0,99]) y una subestimación del SCC evaluado mediante unidades Agatston del 9,8 %. Conclusión: En este estudio, demostramos que el SCC podría ser evaluado con precisión de forma tanto cualitativa como cuantitativa mediante estudios de TC de tórax no gatillada de baja dosis.

ABSTRACT Background: Coronary calcium scoring (CCS) is an underused prevention tool, possibly due to its high cost, which should not differ from a chest computed tomography (CT) scan. CCS can be assessed using conventional chest CT, generally through a visual or semiquantitative approach, and with a similar prognostic value compared to ECG-gated CCS. Methods: In this retrospective observational study, we included patients (n = 35) who underwent a low-dose non-gated chest CT (LDCT) and an ECG-gated CCS within the same hospitalization. Results: We identified a good agreement between techniques both in their qualitative and quantitative assessment, with a mean of 3.86 ± 0.7 segments with calcifications by ECG-gated compared to 3.79 ± 0.6 segments by LDCT (concordance correlation coefficient 0.98 (95% CI 0.95-0.99), and a 9.8% underestimation of the Agatston score. Conclusions: In this study, we showed that the CCS might be accurately assessed both qualitatively and quantitatively by LDCT studies.

Utilidad de la TC espectral cardíaca para la evaluación de complicaciones trombóticas en pacientes con ataque cerebrovascular isquémico / Usefulness of Spectral Cardiac Computed Tomography for the Evaluation of Thrombotic Complications in Patients with Ischemic Stroke

RESUMEN Objetivo: Evaluar la utilidad de la angiotomografía computada (TC) espectral cardíaca en pacientes con ataque cerebrovascular isquémico (ACVi). Material y métodos: En el contexto de pandemia de COVID-19 incorporamos la utilización de la TC espectral cardíaca en pacientes con ACVi para descartar en una única sesión, tanto fuentes cardioembólicas (FCE) como la presencia de complicaciones trombóticas o daño miocárdico. A partir de julio de 2020 incorporamos una adquisición tardía a las TC cardíacas en contexto de ACVi. Se presentan cuatro casos representativos sobre su utilidad y hallazgos cardiovasculares. Resultados: Se presentan cuatro casos registrados en un lapso de 40 días. Dos pacientes con FCE (aorta y orejuela izquierda) y dos con ACVi de origen indeterminado donde se evidenció miocardiopatía (isquémica y no isquémica). Conclusiones: En el contexto del ACVi, la TC espectral cardíaca, que incluía adquisición tardía, permitiría, eventualmente, descartar la presencia de FCE e identificar la etiología subyacente.

ABSTRACT Objective: The aim of this study was to evaluate the usefulness of spectral cardiac computed tomography (CT) angiography in patients with ischemic stroke. Methods: In the setting of COVID-19 pandemic, we incorporated the use of spectral cardiac CT in patients with ischemic stroke to rule out the presence of cardioembolic sources, thrombotic complications or myocardial damage in a single session. Since July 2020, a delayed-phase image acquisition was incorporated to cardiac CT scans in the context of ischemic stroke. We describe four representative cases of the usefulness of the method and the cardiovascular findings. Results: We present four cases recorded recorded within a 40-day period. Two patients with patients with cardioembolic source (aorta and left atrial appendage) and two with ischemic stroke of undetermined source with evidence of cardiomyopathy (ischemic and non-ischemic). Conclusions: In the setting of ischemic stroke, spectral cardiac CT with delayed acquisition could be useful to rule out the presence of cardioembolic sources and identify the underlying etiology.

Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

[Acute ischemic stroke in anterior territory: endovascular treatment]. / Ataque cerebrovascular isquémico agudo de territorio anterior. Tratamiento endovascular.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) = 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS = 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) = 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS = 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Transient acute kidney injury after cardiac surgery does not independently affect postoperative outcomes.

BACKGROUND: The objective of this study was to assess the incidence of in-hospital acute kidney injury (AKI) after cardiac surgery by comparing preoperative baseline renal function with renal function during the postoperative period and at discharge, and to relate these indices with in-hospital postoperative outcomes. METHODS: A retrospective analysis was performed over a 4-year period from a series of 426 adult patients. Kidney function was based on serum creatinine (SCr), Cockroft-Gault estimated creatinine clearance (eCrCl), and glomerular filtration rate estimated with the Modification of Diet in Renal Disease formula (eGFR). Baseline values were compared with "peak" values of altered kidney function postoperatively, and "discharge" values. In-hospital mortality and complication rates were compared between patients with transient and persistent AKI, and those without postoperative AKI. RESULTS: After surgery, AKI (Risk-Injury-Failure-Loss-Endstage [RIFLE] classes Injury and Failure) was diagnosed in 14.6-17.5% of patients based on peak values. AKI diagnosis was reduced to 3.6-4.5% when SCr, eCrCl, and eGFR were measured at discharge. In-hospital mortality of patients with transient AKI was 4% versus 26% in patients with AKI at discharge (odds ratio = 0.11, 95% confidence interval 0.02-0.62, P = 0.011). CONCLUSIONS: A diagnosis of AKI based on measurements of eGFR during the postoperative period was nearly four times more frequent than the same diagnosis at discharge. Transient AKI was the predominate presentation of postoperative kidney dysfunction in this study. Transient AKI did not affect in-hospital outcomes compared with patients without AKI. Patients with persistent AKI at discharge had the highest mortality.

Association of body mass index with short-term outcomes after cardiac surgery: retrospective study and meta-analysis.

The relationship between higher body mass index (BMI), decreased morbidity and mortality is known as the "obesity paradox", and has been described in cohorts of patients with hypertension, diabetes, heart failure, coronary and peripheral artery diseases, non-cardiac surgery, and end-stage renal disease. Here we investigated the relationship between BMI and short-term outcomes after adult cardiac surgery to explore the existence of an obesity paradoxical effect. A secondary objective was to perform an updated systematic review to further analyze the association between BMI and 30-day in-hospital mortality after cardiac surgery. A retrospective analysis was performed from a consecutive series of 1823 adult patients who underwent cardiac surgery, that were assigned to five BMI groups: normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), class I obese (30-34.9 kg/m2), class II obese (35-39.9 kg/m2), and class III obese or morbidly obese (40-49.9 kg/m2). A systematic review search was performed including controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS, and the Cochrane library (to the end of June 2017). In the present series, overweight and obese patients had similar or slightly lower in-hospital mortality rates after cardiac surgery compared with normal-weight individuals. Conversely, postoperative complication rates increased with higher BMI levels. Most studies included in the review showed that overweight and obese patients had at least the same mortality rate as normal-weight patients, or even a lower death risk. Pooled-data of the meta-analysis provided evidence on the association between higher BMI levels and a lower all-cause in-hospital mortality rate after cardiac surgery.

Association of body mass index with short-term outcomes after cardiac surgery: retrospective study and meta-analysis

The relationship between higher body mass index (BMI), decreased morbidity and mortality is known as the "obesity paradox", and has been described in cohorts of patients with hypertension, diabetes, heart failure, coronary and peripheral artery diseases, non-cardiac surgery, and end-stage renal disease. Here we investigated the relationship between BMI and short-term outcomes after adult cardiac surgery to explore the existence of an obesity paradoxical effect. A secondary objective was to perform an updated systematic review to further analyze the association between BMI and 30-day in-hospital mortality after cardiac surgery. A retrospective analysis was performed from a consecutive series of 1823 adult patients who underwent cardiac surgery, that were assigned to five BMI groups: normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), class I obese (30-34.9 kg/m²), class II obese (35-39.9 kg/m²), and class III obese or morbidly obese (40-49.9 kg/m²). A systematic review search was performed including controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS, and the Cochrane library (to the end of June 2017). In the present series, overweight and obese patients had similar or slightly lower in-hospital mortality rates after cardiac surgery compared with normal-weight individuals. Conversely, postoperative complication rates increased with higher BMI levels. Most studies included in the review showed that overweight and obese patients had at least the same mortality rate as normal-weight patients, or even a lower death risk. Pooled-data of the meta-analysis provided evidence on the association between higher BMI levels and a lower all-cause in-hospital mortality rate after cardiac surgery.

La relación entre mayor índice de masa corporal (IMC) y menor morbilidad y mortalidad se conoce como "paradoja de la obesidad". Se ha descrito en cohortes de pacientes con hipertensión, diabetes, insuficiencia cardíaca, enfermedad coronaria y arterial periférica, cirugías no cardíacas y enfermedad renal en etapa terminal. Aquí se investigó la relación entre IMC y resultados a corto plazo después de cirugía cardíaca en adultos, y la manifestación de la paradoja de la obesidad. También se realizó una revisión sistemática sobre asociación entre IMC y mortalidad a 30 días de la cirugía cardíaca. Se hizo un análisis retrospectivo de una serie consecutiva de 1823 adultos con cirugía cardíaca, asignados a cinco grupos de IMC: peso normal (18.5-24.9 kg/m²), sobrepeso (25- 29.9 kg/m²), obesidad clase I (30-34.9 kg/m²), clase II (35-39.9 kg/m²), y clase III (40-49.9 kg/m²), y una búsqueda sistemática de ensayos controlados y estudios observacionales en MEDLINE, Embase, SCOPUS y Cochrane (hasta 30/6/2017). En la serie, las tasas de mortalidad hospitalaria fueron similares o ligeramente menores en pacientes con sobrepeso y obesidad comparados con aquellos de peso normal. Pero también las tasas de complicaciones postoperatorias aumentaron con el IMC. La mayoría de los estudios observacionales revisados mostraron que los pacientes con sobrepeso y obesidad tenían al menos similar tasa de mortalidad que aquellos con peso normal, o menor riesgo de muerte. Los datos combinados del metaanálisis evidenciaron asociación entre los niveles de IMC mayores y tasa de mortalidad hospitalaria más baja después de cirugía cardíaca.

Geometric patterns of time-delay plots from different cardiac rhythms and arrhythmias using short-term EKG signals.

OBJECTIVE: To date, no systematic work has been intended to describe spatio-temporal patterns of cardiac rhythms using only short series of RR intervals, to facilitate visual or computerized-aided identification of EKG motifs for use in clinical practice. The aim of this study was to detect and classify eye-catching geometric patterns of Poincaré time-delay plots from different types of cardiac rhythms and arrhythmias using short-term EKG signals. METHODS: Approximately 150-300 representative, consecutive beats were retrieved from 24-h Holter registers of 100 patients with different heart rhythms. Two-dimensional Poincaré charts were created, and the resulting geometric patterns were transformed into representative familiar eye-catching drawings to interpret different arrhythmias. RESULTS: Poincaré plot representation of RR interval data revealed a wide variety of visual patterns: (i) comet-shaped for sinus rhythm; (ii) torpedo-shaped for sinus bradycardia; (iii) cigarette-shaped for sinus tachycardia; (iv) butterfly-shaped for sinus tachycardia and isolated atrial premature complexes; (v) arrow-shaped for isolated premature complexes and inappropriate sinus tachycardia; (vi) inverted fan-shaped for sinus rhythm with frequent atrial premature complexes; (vii) tornado-shaped for atrial flutter and atrial tachycardia; and (viii) fan-shaped for atrial fibrillation. CONCLUSIONS: Modified Poincaré plots with smoothed lines connecting successive points could accurately classify different types of arrhythmias based on short RR interval sequence variability. Characteristic emergent patterns can be visually identified and eventually could be distinguished by an automatic classification system able to discern between arrhythmias. This work provides an alternative method to interpret time-delay plots obtained from short-term EKG signal recordings.

Validation of age, creatinine and ejection fraction (ACEF) and Cockcroft-Gault ACEF scores in elective cardiac surgery.

The objective of this study was to evaluate the efficacy of age, creatinine and ejection fraction (ACEF) score and the modified ACEFCG model, incorporating creatinine clearance, to predict immediate operative mortality risk of patients undergoing elective cardiac surgery. A retrospective analysis was performed of prospectively collected data between 2012 and 2015, from a series of 1190 adult patients who underwent elective cardiac surgery. Operative risk mortality was assessed with ACEF, ACEFCG and EuroSCORE II. Overall mortality rate was 4.0% (48 cases), while mean mortality rates predicted by ACEF, ACEFCG, and EuroSCORE II were 2.3% (p = 0.014), 6.4% (p = 0.010) and 2.5% (p = 0.038), respectively. Overall observed/predicted mortality ratio was 1.8 for ACEF score, 0.6 for ACEFCG score and 1.6 for EuroSCORE II. The ACEF score demonstrated an adequate overall performance for the low- and intermediate-risk groups, but underestimated mortality for the high risk group. The ACEFCG score discriminatory power systematically improved the area under the ROC curve (AUC) obtained with the ACEF score; however, EuroSCORE II showed the best AUC. Overall accuracy was 56.1% for the ACEF score, 51.2% for the ACEFCG score and 75.9% for EuroSCORE II. For clinical use, the ACEF score seems to be adequate to predict mortality in low- and intermediate-risk patients. Though the ACEFCG score had a better discriminatory power and calibration, it tended to overestimate the expected risk. Since ideally, a simpler risk stratification score should be desirable for bedside clinical use, the ACEF model reasonably met the expected performance in our population.

Validation of age, creatinine and ejection fraction (ACEF) and Cockcroft-Gault ACEF scores in elective cardiac surgery

The objective of this study was to evaluate the efficacy of age, creatinine and ejection fraction (ACEF) score and the modified ACEFCG model, incorporating creatinine clearance, to predict immediate operative mortality risk of patients undergoing elective cardiac surgery. A retrospective analysis was performed of prospectively collected data between 2012 and 2015, from a series of 1190 adult patients who underwent elective cardiac surgery. Operative risk mortality was assessed with ACEF, ACEFCG and EuroSCORE II. Overall mortality rate was 4.0% (48 cases), while mean mortality rates predicted by ACEF, ACEFCG, and EuroSCORE II were 2.3% (p = 0.014), 6.4% (p = 0.010) and 2.5% (p = 0.038), respectively. Overall observed/predicted mortality ratio was 1.8 for ACEF score, 0.6 for ACEFCG score and 1.6 for EuroSCORE II. The ACEF score demonstrated an adequate overall performance for the low- and intermediate-risk groups, but underestimated mortality for the high risk group. The ACEFCG score discriminatory power systematically improved the area under the ROC curve (AUC) obtained with the ACEF score; however, EuroSCORE II showed the best AUC. Overall accuracy was 56.1% for the ACEF score, 51.2% for the ACEFCG score and 75.9% for EuroSCORE II. For clinical use, the ACEF score seems to be adequate to predict mortality in low- and intermediate-risk patients. Though the ACEFCG score had a better discriminatory power and calibration, it tended to overestimate the expected risk. Since ideally, a simpler risk stratification score should be desirable for bedside clinical use, the ACEF model reasonably met the expected performance in our population.

El objetivo fue evaluar la eficacia de la escala de riesgo de edad, creatinina y fracción de eyección (ACEF) y también ACEFCG, que incorpora la depuración de creatinina, para predecir el riesgo de mortalidad operatoria inmediata tras una cirugía cardiaca electiva. Se realizó un análisis retrospectivo de datos recolectados prospectivamente entre 2012 y 2015, de 1190 adultos sometidos a cirugía cardíaca electiva. El riesgo de mortalidad operatoria se evaluó con ACEF, ACEFCG y EuroSCORE II. La tasa de mortalidad global fue 4.0% (48 casos), mientras que las tasas de mortalidad predichas por ACEF, ACEFCG y EuroSCORE II fueron 2.3% (p = 0.014), 6.4% (p = 0.010) y 2.5% (p = 0.038), respectivamente. La razón mortalidad observada/esperada fue 1.8 para el ACEF, 0.6 para el ACEFCG y 1.6 para el EuroSCORE II. La puntuación de ACEF demostró un desempeño adecuado para los grupos de riesgo bajo y medio, pero subestimó la mortalidad del grupo de alto riesgo. La discriminación del ACEFCG mejoró sistemáticamente el área ROC del ACEF; sin embargo, el EuroSCORE II mostró la mejor área ROC. La precisión global fue 56.1% para el ACEF, 51.2% para el ACEFCG y 75.9% para el EuroSCORE II. Para uso clínico, el modelo ACEF parece ser adecuado para predecir la mortalidad en pacientes de riesgo bajo y medio. Aunque el puntaje de ACEFCG tuvo un mejor poder discriminatorio y calibración, tendió a sobrestimar el riesgo esperado. Considerando que sería ideal contar con un método de estratificación de riesgo más simple para uso clínico al lado de la cama, el modelo ACEF tuvo un desempeño razonable en nuestra población.

Incidence of prosthesis-patient mismatch in patients receiving mitral Biocor® porcine prosthetic valves.

BACKGROUND: The aim was to assess the incidence of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) in patients receiving Biocor® porcine or mechanical valves, and to evaluate the effect of PPM on long-term survival. METHODS: All patients undergoing MVR between 2009 and 2013 received either mechanical or bioprosthetic valves (Biocor® porcine). PPM was defined as severe when the indexed effective ori-fice area was < 0.9 cm2/m2, moderate between 0.9 cm2/m2 and 1.2 cm2/m2 or absent > 1.2 cm2/m2. The primary endpoint was all-cause long-term mortality. RESULTS: Among a total of 136 MVR, PPM was severe in 27%, moderate in 44% and absent in 29% of patients. Implanted valves were 57% mechanical and 43% bioprosthetic. Only 3% of patients with mechanical valves had severe PPM vs. 59% with bioprostheses (p < 0.0001). Sixty-month survival with severe mismatch was 0.559 (SE 0.149) and with no mismatch 0.895 (SE 0.058) (p = 0.043). Survival of patients suffering from severe mismatch, or moderate mismatch with pulmonary hypertension (PH) was 0.749 (SE 0.101); while for patients with no mismatch or with moderate mismatch without PH, survival was 0.951 (SE 0.028) (p = 0.016). CONCLUSIONS: About one-fourth of patients had severe PPM and almost all of them had received a bioprosthesis. Sixty-month survival was significantly lower in patients with severe mismatch, or moderate mismatch with PH. Specifically, when a bioprothesis is chosen and while further evidence on the impact of PPM on clinical outcomes appears, surgeons are recommended to follow a preoperative strategy to implant a mitral prosthesis of adequate size in order to prevent PPM.

Routine operation theatre extubation after cardiac surgery in the elderly.

OBJECTIVES: The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. METHODS: A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. RESULTS: Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). CONCLUSIONS: OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.

Prospective validation of EuroSCORE II in patients undergoing cardiac surgery in Argentinean centres.

OBJECTIVES: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is an updated version of the original EuroSCORE that must be extensively validated. The objective was to prospectively evaluate the efficacy of EuroSCORE II in predicting the immediate results of cardiac surgery in Argentinean centres. METHODS: A prospective consecutive series of 503 adults who underwent cardiac surgery between January 2012 and April 2013 was studied. EuroSCORE II discrimination and accuracy were assessed in the overall cohort and in two surgically defined subgroups: isolated coronary artery bypass graft (CABG) surgery and non-CABG surgery. Additionally, a risk-adjusted cumulative sum control chart analysis was performed. RESULTS: In-hospital overall mortality rate was 4.17%, while the mortality rate predicted by the EuroSCORE II was 3.18% (P = 0.402). Receiver operating characteristic curve analysis demonstrated a good overall (area 0.856) and non-CABG subgroup (area 0.857) discrimination (P = 0.0001), while discrimination in the CABG subgroup was poorer (area 0.794, P = 0.014). The model showed good calibration in predicting in-hospital mortality, both overall (Hosmer-Lemeshow, P = 0.082) and for each subgroup (non-CABG, P = 0.308, and CABG, P = 0.150). CONCLUSIONS: EuroSCORE II reflects a better current surgical performance and offers a new quality standard to evaluate local outcomes. EuroSCORE showed an overall good discriminative capacity and calibration in this local population; nevertheless, the model performed optimally in non-CABG surgery and in highest-risk patients, underestimating in-hospital mortality in lowest-risk cases. The latter finding may be interpreted as an inadequate behaviour of the model, as a poor performance of surgeons or both. Larger prospective studies will elucidate this hypothesis.

Resultados hospitalarios y factores asociados con morbimortalidad del Registro Argentino de Angioplastia Coronaria (RAdAC) / Primary Outcomes and Morbi-mortality Associated Factors in the Coronary Angioplasty Argentine Registry - RAdAC / Primary Outcomes and Morbi-mortality Associated Factors in the Coronary Angioplasty Argentine Registry - RAdAC

Introducción En el Registro CONAREC V, de 1996, se recopilaron los resultados obtenidos con angioplastia transluminal coronaria (ATC) y posteriormente, durante 2005, se recabaron datos con similar metodología generándose el Registro CONAREC XIV. Desde entonces no se cuenta con datos nacionales generales en relación con la revascularización coronaria percutánea, por lo que la Sociedad Argentina de Cardiología, en conjunto con el CACI, la FAC y el CONAREC, implementó el Registro Argentino de Angioplastia Coronaria (RAdAC). Objetivo Evaluar a escala nacional los resultados intrahospitalarios y la morbimortalidad de pacientes sometidos a ATC según los distintos escenarios clínicos. Material y métodos En un período de 7 meses se incluyeron 1.905 pacientes en forma prospectiva y consecutiva en 67 centros de la Argentina. Se analizaron factores de riesgo, antecedentes cardiovasculares y cuadro clínico. La ATC se consideró programada, de urgencia y de emergencia, y se estimó el número de vasos enfermos y la intención de vasos a tratar y la cantidad y tipo de stents convencionales (SC) y liberadores de droga (SLD);. Se analizó el empleo de aterectomía, Cutting Balloon«, tromboaspiración, ultrasonido intravascular (IVUS), antiagregantes y balón de contrapulsación intraaórtico (BCIA). El éxito angiográfico se definió como lesión residual < 20% y flujo normal (TIMI 3). Resultados La edad promedio fue de 63,8 años. Un total de 752 pacientes (39,5%) presentaban infarto agudo de miocardio (IAM) y 834 pacientes (43,8%) angina inestable (AI). Se utilizó acceso femoral en el 92,8% de los casos. El 44,3% de las intervenciones fueron programadas, el 37,8%, de urgencia y el 17,9%, de emergencia. Se implantaron 2.753 stents (1,4 por paciente) con 33,2% de SLD. El éxito primario fue del 97% y la mortalidad global observada, del 1,6%; la asociada con infarto ascendió al 3,2% (con ST 4,3%, sin ST 1,7%), la de AI fue del 0,8% y la de angina crónica estable, del 0,3%. Las variables asociadas con el óbito fueron shock cardiogénico, necesidad de BCIA, Killip y Kimball 3-4, ATC de emergencia, ATC del tronco, mala función ventricular, insuficiencia renal o diabetes, mayor número de vasos enfermos, mayor edad y fracaso de la ATC. Conclusiones En nuestro medio, la mayoría de las ATC se realizan en síndromes coronarios agudos y casi exclusivamente por vía femoral, con éxito primario comparable a datos internacionales pero con menor utilización de SLD. El empleo de Rotablator«, Cutting Balloon«, tromboaspiración, IVUS y BCIA fue más bajo que el esperado, mientras que la edad, el shock cardiogénico, la emergencia y la ATC fallida resultaron factores asociados con mayor morbimortalidad.(AU)

Background Percutaneous transluminal coronary angioplasty (PTCA) outcomes were compiled in the 1996 V CONAREC Registry, and in 2005, data collection was repeated using a similar methodology, giving rise to the XIV CONAREC Registry. As no general national PTCA results have been reported since, the Argentine Society of Cardiology, together with CACI, FAC and CONAREC carried out the Coronary Angioplasty Argentine Registry (RAdAC). Objective The aim of this Registry was to evaluate intrahospital outcome and morbi-mortality of patients submitted to PTCA according to different clinical scenarios. Methods One thousand nine hundred and five patients were prospectively and consecutively included in 67 centers of Argentina during a 7-month period. Cardiovascular risk factors and clinical history were analyzed. PTCA procedures were classified as: planned, urgent or emergent and the number of affected and intended-to-treat vessels, as well as the number and type of stents implanted bare metal (BMS) or drug-eluting stents (DES); were estimated. Use of atherectomy, Cutting Balloon?, thrombus aspiration, intravascular ultrasound (IVUS), antiplatelet drugs and intra-aortic balloon pump (IABP) was analyzed. Angiographic success was defined as residual lesion <20% and normal flow (TIMI 3). Results Mean age was 63.8 years. A total of 752 patients (39.5%) presented with acute myocardial infarction (AMI) and 834 patients (43.8%) with unstable angina (UA). Femoral access was used in 92.8% of the cases. Overall, 44.3% of the interventions were planned, 37.8% were urgent and 17.9% emergent. A total of 2753 stents were implanted (1.4 per patient), 33.2% of which were DES. The primary success rate was 97% and overall mortality 1.6%: 3.2% associated to AMI, (4.3% STEMI and 1.7% non-STEMI), 0.8% to UA and 0.3% to chronic stable angina. Death-associated variables were: cardiogenic shock, need of IAPB, Killip-Kimball class 3-4, emergency PTCA, left main PTCA, ventricular function impairment, renal failure or diabetes, number of affected vessels, age and PTCA failure. Conclusions In our setting, most PTCAs are performed in acute coronary syndromes, almost exclusively by femoral access, with primary success comparable to that of international reports, but employing less DES. Use of Rotablator, Cutting Balloon?, thrombus aspiration, IVUS and IABP implementation was lower than expected, while age, cardiogenic shock, emergency and PTCA failure were factors associated with increased morbi-mortality.(AU)

Resultados hospitalarios y factores asociados con morbimortalidad del Registro Argentino de Angioplastia Coronaria (RAdAC) / Primary Outcomes and Morbi-mortality Associated Factors in the Coronary Angioplasty Argentine Registry - RAdAC / Primary Outcomes and Morbi-mortality Associated Factors in the Coronary Angioplasty Argentine Registry - RAdAC

Introducción En el Registro CONAREC V, de 1996, se recopilaron los resultados obtenidos con angioplastia transluminal coronaria (ATC) y posteriormente, durante 2005, se recabaron datos con similar metodología generándose el Registro CONAREC XIV. Desde entonces no se cuenta con datos nacionales generales en relación con la revascularización coronaria percutánea, por lo que la Sociedad Argentina de Cardiología, en conjunto con el CACI, la FAC y el CONAREC, implementó el Registro Argentino de Angioplastia Coronaria (RAdAC). Objetivo Evaluar a escala nacional los resultados intrahospitalarios y la morbimortalidad de pacientes sometidos a ATC según los distintos escenarios clínicos. Material y métodos En un período de 7 meses se incluyeron 1.905 pacientes en forma prospectiva y consecutiva en 67 centros de la Argentina. Se analizaron factores de riesgo, antecedentes cardiovasculares y cuadro clínico. La ATC se consideró programada, de urgencia y de emergencia, y se estimó el número de vasos enfermos y la intención de vasos a tratar y la cantidad y tipo de stents convencionales (SC) y liberadores de droga (SLD);. Se analizó el empleo de aterectomía, Cutting Balloon®, tromboaspiración, ultrasonido intravascular (IVUS), antiagregantes y balón de contrapulsación intraaórtico (BCIA). El éxito angiográfico se definió como lesión residual < 20% y flujo normal (TIMI 3). Resultados La edad promedio fue de 63,8 años. Un total de 752 pacientes (39,5%) presentaban infarto agudo de miocardio (IAM) y 834 pacientes (43,8%) angina inestable (AI). Se utilizó acceso femoral en el 92,8% de los casos. El 44,3% de las intervenciones fueron programadas, el 37,8%, de urgencia y el 17,9%, de emergencia. Se implantaron 2.753 stents (1,4 por paciente) con 33,2% de SLD. El éxito primario fue del 97% y la mortalidad global observada, del 1,6%; la asociada con infarto ascendió al 3,2% (con ST 4,3%, sin ST 1,7%), la de AI fue del 0,8% y la de angina crónica estable, del 0,3%. Las variables asociadas con el óbito fueron shock cardiogénico, necesidad de BCIA, Killip y Kimball 3-4, ATC de emergencia, ATC del tronco, mala función ventricular, insuficiencia renal o diabetes, mayor número de vasos enfermos, mayor edad y fracaso de la ATC. Conclusiones En nuestro medio, la mayoría de las ATC se realizan en síndromes coronarios agudos y casi exclusivamente por vía femoral, con éxito primario comparable a datos internacionales pero con menor utilización de SLD. El empleo de Rotablator®, Cutting Balloon®, tromboaspiración, IVUS y BCIA fue más bajo que el esperado, mientras que la edad, el shock cardiogénico, la emergencia y la ATC fallida resultaron factores asociados con mayor morbimortalidad.

Background Percutaneous transluminal coronary angioplasty (PTCA) outcomes were compiled in the 1996 V CONAREC Registry, and in 2005, data collection was repeated using a similar methodology, giving rise to the XIV CONAREC Registry. As no general national PTCA results have been reported since, the Argentine Society of Cardiology, together with CACI, FAC and CONAREC carried out the Coronary Angioplasty Argentine Registry (RAdAC). Objective The aim of this Registry was to evaluate intrahospital outcome and morbi-mortality of patients submitted to PTCA according to different clinical scenarios. Methods One thousand nine hundred and five patients were prospectively and consecutively included in 67 centers of Argentina during a 7-month period. Cardiovascular risk factors and clinical history were analyzed. PTCA procedures were classified as: planned, urgent or emergent and the number of affected and intended-to-treat vessels, as well as the number and type of stents implanted bare metal (BMS) or drug-eluting stents (DES); were estimated. Use of atherectomy, Cutting Balloon?, thrombus aspiration, intravascular ultrasound (IVUS), antiplatelet drugs and intra-aortic balloon pump (IABP) was analyzed. Angiographic success was defined as residual lesion <20% and normal flow (TIMI 3). Results Mean age was 63.8 years. A total of 752 patients (39.5%) presented with acute myocardial infarction (AMI) and 834 patients (43.8%) with unstable angina (UA). Femoral access was used in 92.8% of the cases. Overall, 44.3% of the interventions were planned, 37.8% were urgent and 17.9% emergent. A total of 2753 stents were implanted (1.4 per patient), 33.2% of which were DES. The primary success rate was 97% and overall mortality 1.6%: 3.2% associated to AMI, (4.3% STEMI and 1.7% non-STEMI), 0.8% to UA and 0.3% to chronic stable angina. Death-associated variables were: cardiogenic shock, need of IAPB, Killip-Kimball class 3-4, emergency PTCA, left main PTCA, ventricular function impairment, renal failure or diabetes, number of affected vessels, age and PTCA failure. Conclusions In our setting, most PTCAs are performed in acute coronary syndromes, almost exclusively by femoral access, with primary success comparable to that of international reports, but employing less DES. Use of Rotablator, Cutting Balloon?, thrombus aspiration, IVUS and IABP implementation was lower than expected, while age, cardiogenic shock, emergency and PTCA failure were factors associated with increased morbi-mortality.

Tratamiento endovascular de los aneurismas toracoabdominales tipo IV / Endovascular Repair of Type IV Thoracoabdominal Aneurysms

Los pacientes con aneurismas toracoabdominales tipo IV se caracterizan anatómicamente por la presencia de una dilatación aórtica visceral que determina la falta de un cuello proximal aórtico adecuado para el anclaje de las endoprótesis convencionales. Para tal fin existen injertos especialmente diseñados con fenestraciones. En esta comunicación se describe la experiencia de un grupo quirúrgico en la utilización de endoprótesis fenestradas. Fueron tratados seis pacientes. Todas las endoprótesis fueron implantadas con éxito, respetando 20 vasos viscerales. Este abordaje constituye hoy una alternativa válida para el tratamiento de este grupo de pacientes candidatos a cirugía convencional de alto riesgo.

Endovascular Repair of Type IV Thoracoabdominal Aneurysms Type IV thoracoabdominal aortic aneurysms are characterized by involvement of the visceral aortic segment which determines the lack of a proximal aortic neck suitable for the implantation conventional stents. Fenestrated stents have been specially developed for these cases. We describe the experience of a surgical center using fenestrated stents in six patients. All the stents were successfully implanted, respecting 20 visceral vessels. This approach is a valid alternative for patients who are at high risk for conventional surgery.

Tratamiento endovascular de los aneurismas toracoabdominales tipo IV / Endovascular Repair of Type IV Thoracoabdominal Aneurysms

Los pacientes con aneurismas toracoabdominales tipo IV se caracterizan anatómicamente por la presencia de una dilatación aórtica visceral que determina la falta de un cuello proximal aórtico adecuado para el anclaje de las endoprótesis convencionales. Para tal fin existen injertos especialmente diseñados con fenestraciones. En esta comunicación se describe la experiencia de un grupo quirúrgico en la utilización de endoprótesis fenestradas. Fueron tratados seis pacientes. Todas las endoprótesis fueron implantadas con éxito, respetando 20 vasos viscerales. Este abordaje constituye hoy una alternativa válida para el tratamiento de este grupo de pacientes candidatos a cirugía convencional de alto riesgo.(AU)

Endovascular Repair of Type IV Thoracoabdominal Aneurysms Type IV thoracoabdominal aortic aneurysms are characterized by involvement of the visceral aortic segment which determines the lack of a proximal aortic neck suitable for the implantation conventional stents. Fenestrated stents have been specially developed for these cases. We describe the experience of a surgical center using fenestrated stents in six patients. All the stents were successfully implanted, respecting 20 visceral vessels. This approach is a valid alternative for patients who are at high risk for conventional surgery.(AU)