Preoperative Use of Intra-Aortic Balloon Pump Support Reduced 30-Day Mortality in a Population with LVEF >35% and High Surgical Risk after Coronary Artery Bypass Graft Surgery.

INTRODUCTION: The intra-aortic balloon pump (IABP) is used to prevent complications after coronary artery bypass grafting (CABG) surgery, although some results are controversial and basal ventricular function may play a role. This study assessed the benefit of preoperative use of IABP, as stratified by the ventricular function, in a population submitted to high-surgical-risk CABG. METHODS: Patients >18 years old, with multiple coronary artery disease and thus candidates for CABG, were included. Cardiogenic shock, acute myocardial infarction (AMI), acute ventricle mechanical dysfunction, severe aortic regurgitation, tachyarrhythmia, massive pulmonary embolism, coagulopathy, or low life expectancy were exclusion criteria. RESULTS: One hundred and twenty-nine patients aged 65 years old with hypertension, dyslipidemia, type 2 diabetes mellitus, and mean left ventricular ejection fraction (LVEF) 46% constituted the study population. No difference was observed at 30-day mortality endpoint (IABP vs. no IABP, 17 vs. 24%, OR 0.63, p = 0.20; AMI 25 vs. 31%, OR 0.75, p = 0.29). After LVEF stratification, the subgroup of 48 (75%) patients under IABP support and LVEF >35% had a reduced 30-day mortality risk (LVEF ≤35% vs. LVEF >35%, 37.5 vs. 10.4%, OR 0.3, p = 0.03), independently from potential confounders and showing an interaction with European System for Cardiac Operative Risk Evaluation-II (EuroSCORE-II). At secondary endpoints, IABP use was associated with a lower prevalence of acute renal failure and renal replacement therapy, but with a longer stay in the intensive care unit and longer hospitalization time. CONCLUSION: The preoperative use of IABP was associated with an independent reduction of 30-day mortality risk in cases with LVEF >35% in a population submitted to high-surgical-risk CABG. Likewise, the use of IABP was associated with a lower risk of postoperative renal complications.

Síndrome de Wellens, equivalente clínico de estenosis coronaria crítica / Wellens' syndrome, clinical equivalent of critical coronary stenosis

Resumen El infarto agudo de miocardio con elevación del segmento ST es una indicación urgente de cateterismo cardiaco. El síndrome de Wellens es la inversión persistente de la onda T en las derivaciones V2 y V3 con datos clínicos compatibles con angina; la evidencia de este síndrome indica la oclusión crítica de la coronaria descendente anterior; el tratamiento de elección es el cateterismo cardiaco. Se comunica el caso clínico de un paciente con factores de riesgo cardiovascular, con evidencia de síndrome de Wellens tipo B; el reconocimiento y la adecuada toma de decisiones son críticas en estas circunstancias.

Abstract Acute myocardial infarction with ST elevation is an urgent indication for cardiac catheterization. Wellens' syndrome is a persistent reversal of the T wave in leads V2 and V3 with clinical presence compatible with angina; the evidence of this syndrome indicates the critical occlusion of the anterior descending coronary artery, with cardiac catheterization being the treatment of choice. We present the clinical case of a patient with cardiovascular risk factors, with evidence of Wellens' syndrome type B. Recognition and proper decision-making are critical in these circumstances.

Intramyocardial dissecting hematoma of the right ventricle secondary to acute myocardial infarction. Case report / Hematoma intramiocárdico disecante del ventrículo derecho secundario a infarto agudo de miocardio. Reporte de caso

Abstract: Background: Intramyocardial dissecting haematoma is a rare form of cardiac rupture that can occur as a complication following acute myocardial infarction or during the remodelling process, with very scarce reports in medical literature. Usually caused by a haemorrhagic dissection among the spiral myocardial fibres. Case report: Here we report the case of a 60-year-old man with a previous infarction in the inferior wall extended to the right ventricle, in whom a dissecting intramyocardial haematoma in the free wall of the right ventricle was identified using transthoracic and contrast echocardiography, corroborated with cardiac magnetic resonance. Results: By this imaging modalities, it was possible to see the various acoustic densities of the progressive clotting of the hematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Conclusion: The patient presented a gradual improvement and hemodynamic stability, and basing on the existent medical literature, it was decided the medical treatment as the therapeutic option, maintaining asymptomatic after three months of follow-up.

Resumen: Antecedentes: El hematoma intramiocárdico disecante es una forma rara de ruptura cardiaca que puede ocurrir como una complicación posterior al infarto agudo de miocardio o durante el proceso de remodelación del mismo, con informes muy escasos en la literatura médica. Generalmente causada por una disección hemorrágica entre las fibras espirales del miocardio. Caso clínico: Se presenta el caso de un hombre de 60 años con infarto previo en la pared inferior extendido al ventrículo derecho, en el que se identificó un hematoma intramiocárdico disecante en la pared libre del ventrículo derecho mediante ecocardiografía transtorácica y contrastada, corroborado con resonancia magnética cardiaca. Resultados: Por medio de estas modalidades de imagen se pudieron observar las distintas densidades acústicas de la coagulación progresiva del hematoma, su extensión a través de la disección hemorrágica, así como su independencia en relación con las cavidades ventriculares y el espacio extracardiaco, confirmando las capas epicárdicas y endocárdicas indemnes. Conclusión: El paciente presentó una mejoría gradual y estabilidad hemodinámica, y basándose en la literatura médica existente, se decidió el tratamiento médico como opción terapéutica, manteniéndose asintomático después de tres meses de seguimiento.