Echocardiogram by apical-subcostal protocol in prone position during invasive mechanical ventilation in cardiovascular intensive care unit.

AIMS: To evaluate the feasibility of a transthoracic echocardiogram using an apical-subcostal protocol in invasive mechanical ventilation (IMV) and prone position. METHODS: Prospective study of adults who required a prone position during IMV. A pillow was placed only under the left hemithorax in the prone position to elevate and ease the apical and subcostal windows. A critical care cardiologist (prone group) acquired and evaluated the images using the apical-subcostal protocol. Besides, we used ambulatory echocardiograms performed as a comparative group (supine group). RESULTS: 86 patients were included, 43 in the prone and 43 in the supine. In the prone group, the indication to perform an echocardiogram was hemodynamic monitoring. All patients were ventilated with protective parameters, and the mean end-expiratory pressure was 10.6 cmH2O. The protocol was performed entirely in 42 of 43 patients in the prone group because one patient did not have any acoustic window. In the 43 patients in the prone group analyzed and compared to the supine group, global biventricular function was assessed in 97.7% (p = 1.0), severe heart valve disease in 88.4% (p = 0.055), ruled out of the presence of pulmonary hypertension in 76.7% (p = 0.80), pericardial effusion in 93% (p = 0.12), and volume status by inferior vena cava in 93% (p = 0.48). Comparing prone versus supine position, a statistical difference was found when evaluating the left ventricle apical 2-chamber view (65.1 versus 100%, p < 0.01) and its segmental function (53.4 versus 100%, p < 0.01). CONCLUSION: The echocardiogram using an apical-subcostal protocol is feasible in patients in the IMV and prone position.

Prevalencia, caracterización y pronóstico de pacientes con sospecha de insuficiencia cardíaca en atención primaria de salud en Chile / Characterization and prognosis of patients with suspected heart failure at primary health care institutions in Chile

Introducción: La insuficiencia cardíaca (IC) tiene alta morbilidad y mortalidad. Su diagnóstico temprano en atención primaria de salud (APS) es un reto dada la baja especificidad de sus criterios clínicos y las limitaciones en acceso a técnicas diagnósticas. Objetivo: Analizar la prevalencia de IC, subtipos y pronóstico de pacientes con disnea y/o edema de extremidades inferiores que consultan en APS. Metodología: Se trata de un estudio prospectivo de 340 pacientes en APS, sin diagnóstico previo de IC. Se realizó una evaluación clínica, electrocardiograma, NT-proBNP "point-of-care", ecocardiografía con interpretación telemática por cardiólogos. Utilizando los algoritmos HFA-PEFF y H2FPEF se clasificaron los pacientes como :1) IC con fracción de eyección (FE) reducida (ICFER); 2) IC con FE preservada (ICFEP) y 3) pacientes sin diagnóstico de IC. Se efectuó un análisis de sobrevida de los diferentes grupos. Resultados: La prevalencia de ICFER fue 8%, ICFEP por HFA-PEFF 42% y por H2FPEF 8%. Los algoritmos sugieren efectuar un estudio complementario en el 47% con HFA-PEFF y 76% con H2FPEF (p<0.05). La sobrevida global a 36 meses fue 90±2% y cardiovascular 95±1%. Usando HFA-PEFF, los pacientes con IC tuvieron menor sobrevida que aquellos sin IC (HR 2.3, IC95% 1.14.9; p=0.029). No hubo diferencias de mortalidad con H2FPEF. Conclusiones: En pacientes de APS que consultan por disnea y/o edema de extremidades inferiores sometidos a evaluación con NT-proBNP y ecocardiografía, se observó una prevalencia de IC de hasta 50%, 8% de ICFER y 42% de ICFEP. La caracterización de IC utilizando HFA-PEFF está asociada al pronóstico vital.

Background: Heart failure (HF) is a condition associated with high morbidity and mortality. Its early diagnosis in primary health care (PHC) represents a substantial challenge, considering its non-specific clinical manifestations and the limitations on timely access to diagnostic techniques. Objective: To evaluate the prevalence of HF, characterize subtypes and determine the prognosis of patients consulting in PHC for dyspnea Edema of the lower extremities. Methods: Prospective study in 340 patients who consulted in PHC, without previous diagnosis of HF. Clinical evaluation, electrocardiogram, NT-proBNP point-ofcare and echocardiography with telematic interpretation by cardiologists were performed. Using the HFA-PEFF and H2FPEF algorithms patients were classified as: 1) HF with reduced ejection fraction (HFREF); 2) HF with preserved ejection fraction (HFPEF) and 3) No HF. Actuarial survival analyses were performed. Results: We observed a prevalence of HFREF of 8%, high probability of HFPEF by HFA-PEFF in 42% and by H2FPEF in 8%. Intermediate probability of HFPEF, requiring complementary study, was observed in 47% of patients with HFA-PEFF and 76% of patients with H2FPEF (p<0.05). Overall survival at 36 months was 90±2% and cardiovascular survival at 36 months was 95±1%. Using HFA-PEFF, patients with HF presented lower overall survival compared to patients with no HF (HR 2.3, 95%CI 1.1-4.9; p=0.029). We did not observe mortality differences with H2FPEF. Conclusions: In patients consulting for dyspnea and/or lower extremity edema at PHC and undergoing evaluation with NT-proBNP and echocardiography, we observed a HF prevalence of 50%. HF classification through HFA-PEFF was associated with lower survival rates.

[Invasive mucormycosis during COVID-19 infection. Report of two cases]. / Mucormicosis invasora en pacientes con COVID-19: reporte de 2 casos.

COVID-19 disease is associated with a significant number of opportunistic infections, including invasive fungal infections such as mucormycosis. The prevalence of the latter is rare, estimated to be between 0.005 and 1.7 per million inhabitants. Risk factors include hematological diseases, Diabetes Mellitus with poor metabolic control, solid organ transplantation, neutropenia, and prolonged administration of systemic corticosteroids. We report two males aged 60 and 75 years with pulmonary and tracheobronchial invasive mucormycosis, respectively. Both patients had a deficient metabolic control of their diabetes as a predisposing risk factor added to severe COVID-19 infection. High suspicion and early diagnosis are essential for prompt treatment, especially considering the associated high morbidity and mortality of this fungal infection.

Mucormicosis invasora en pacientes con COVID-19: reporte de 2 casos / Invasive mucormycosis during COVID-19 infection. Report of two cases

COVID-19 disease is associated with a significant number of opportunistic infections, including invasive fungal infections such as mucormycosis. The prevalence of the latter is rare, estimated to be between 0.005 and 1.7 per million inhabitants. Risk factors include hematological diseases, Diabetes Mellitus with poor metabolic control, solid organ transplantation, neutropenia, and prolonged administration of systemic corticosteroids. We report two males aged 60 and 75 years with pulmonary and tracheobronchial invasive mucormycosis, respectively. Both patients had a deficient metabolic control of their diabetes as a predisposing risk factor added to severe COVID-19 infection. High suspicion and early diagnosis are essential for prompt treatment, especially considering the associated high morbidity and mortality of this fungal infection.

The Cortical Shield for Facial Bone Reconstruction of Severely Damaged Sockets with Simultaneous Implant Placement: A Feasibility Clinical Trial.

PURPOSE: To evaluate a novel proof-of-principle technique of simultaneous bone regeneration and implant placement in severely damaged sockets. MATERIALS AND METHODS: This study consisted of patients who required a single implant and presented with severe facial bone loss. Individuals were randomly assigned to either the immediate or delayed implant placement protocol. Socket reconstruction and simultaneous implant placement were performed through periosteal-guided bone regeneration. Implants were encased in a customized shield of autogenous cortical bone harvested from an adjacent site. Re-entry surgery was performed at 12 to 18 weeks. Peri-implant tissues and pink esthetics were assessed following established success criteria. RESULTS: Of the 34 patients treated, 28 patients-consisting of 15 women and 13 men with an average age of 50.8 ± 4.5 years-continued to the final follow-up. All individuals showed new facial cortical bone regeneration at second-stage implant surgery after an average healing time of 14.9 ± 2.2 weeks (range: 12 to 18 weeks). Implants remained stable after loading. Success rates were 100% at 12 months. Mean pink esthetic score (PES) was 7.8 ± 1.2 (range: 6 to 9 on a scale of 0 to 10). Linear regression analysis showed that provisionalization and attachment loss are independent risk factors affecting pink esthetics (P < .01). Mild and moderate/severe attachment loss decrease pink esthetic scores by 0.9 and 1.7 points, respectively (95% CI: 0.2-1.5; P < .01). The use of provisional restorations improves pink esthetic scores by 1.6 points (95% CI: 0.8-2.4; P < .001). A PES > 7 was four and five times more likely to be expected for delay and immediate implants, respectively, if the implant had a provisional restoration delivered post-second-stage (RR = 4 to 5; 95% CI: 1-31; P = .07; P = .02). Cramér's V test showed a strong association between lack of implant provisionals and low pink esthetic scores (≤ 7, value = 0.7; P = .02). Facial implant transparency at follow-up was absent, and all implants had a band of keratinized tissue > 2 mm. CONCLUSION: Facial bone regeneration and simultaneous implant placement is feasible in severely damaged sockets through periosteal-guided bone regeneration after a short healing period following immediate or delayed protocols. The assisted regenerated intrasocket bone allows for functional implant stability. Adjacent tooth attachment loss and lack of implant provisionalization negatively impacts pink esthetics. The proposed approach decreases costs, morbidity, and treatment duration and eliminates the need for multi-stage approaches.

Chronic angina secondary to Takayasu arteritis. Report of one case / Síndrome coronario crónico secundario a aortitis y enfermedad coronaria ostial bilateral. Informe de un caso

Chronic coronary syndromes are usually considered uncommon in young women, related to slower progression of atherosclerotic coronary artery disease, have atypical clinical presentations, and experience less diagnostic investigation. Non-atherosclerotic causes of coronary artery disease should be considered in young women experiencing angina. We report a 25-year-old woman who consulted for five months of moderate exertion angina. Physical examination revealed a right carotid bruit and asymmetrical upper extremity peripheral pulses. Initial work-up and imaging allowed to diagnose aortitis with bilateral coronary ostial stenosis secondary to Takayasu's arteritis. The patient experienced an apparent clinical response to initial medical therapy. However, follow-up evaluation revealed persistence of significant ischemia and requirement for myocardial revascularization. A percutaneous coronary intervention was performed.

Los síndromes coronaries crónicos son infrecuentes en mujeres jóvenes, quienes suelen presentar una lenta progresión de enfermedad coronaria aterosclerótica, tienen presentación clínica atípica y son menos sujetas a exploración diagnostica. Se deben considerar causas no ateroscleróticas de enfermedad coronaria en mujeres jóvenes con angina. Informamos una paciente de 25 años que consultó por cinco meses de angina con esfuerzos moderados. Al examen físico presentaba un soplo carotideo derecho y pulsos asimétricos de extremidades superiores. La exploración de laboratorio inicial y posterior evaluación multimodal permitió evidenciar la presencia de aortitis y estenosis de ambos ostium coronarios, concordante con el diagnóstico de una arteritis de Takayasu. Inició terapia medica con respuesta clínica aparentemente favorable. No obstante, la evaluación cardiológica no invasiva en el seguimiento permitió corroborar la persistencia de isquemia significativa y necesidad de revascularización miocárdica. Se realizó una intervención coronaria percutánea de ambos ostium, con una evolución favorable.

Aneurisma de seno de valsalva fistulizado a auricula derecha / Fístula of sinus of valsalva aneurysm to the right atrium

Resumen: Los aneurismas de seno de Valsalva son una malformación rara de observar en la práctica clínica. Se presentan a cualquier edad y pueden ser de origen congénito o adquirido. La importancia de su estudio radica en que potencialmente pueden complicarse con rotura y fistulización a otra estructura cardíaca o extracardíaca, con una alta mortalidad asociada. El diagnóstico muchas veces puede ser complejo, pero existen algunos elementos clínicos inespecíficos que pueden orientarnos en su detección y rápido manejo, lo que puede marcar una diferencia en el pronóstico del paciente. Se presenta el caso de un paciente de 49 años con un aneurisma de seno de Valsalva complicado y a continuación una breve revisión del tema.

Abstract: Aneurysms of the sinus of Valsalva are. They occur at any age, either as a congenital or an acquired malformation. They may rupture and form a fístula to other cardiac structures, with a high mortality rate. The clinical case of a 49 year-old patient with a ruptured sinus of Valsalva an a fístula to the right atrium is presented. A brief review of the subject is included.

Complicaciones cardiovasculares en pacientes COVID-19 hospitalizados en Unidades de Pacientes Críticos en Chile. Registro COVICAR / Cardiovascular complications in COVID-19 patients admitted to intensive care units in Chilean hospitals

BACKGROUND: Patients with a cardiovascular (CV) history may be at greater risk of becoming ill and die due to SARS-CoV-2. AIM: To assess the incidence of CV complications in COVID-19 patients, the type of complication, and their association with CV history. MATERIAL AND METHODS: The clinical course of 1,314 patients with COVID-19 admitted consecutively to critical care units of 10 Chilean hospitals was registered between April and August of 2020. RESULTS: The median age of patients was 59 years and 66% were men. One hundred-four (8%) had a CV history, namely heart failure (HF) in 53 (4.1%), coronary heart disease in 50 (3.8 %), and atrial fibrillation in 36 (2.7 %). There were CV complications in 359 patients (27.3%). The most common were venous thrombosis in 10.7% and arrhythmias in 10.5%, HF in 7.2%, type 2 acute myocardial infarction in 4.2%, arterial thrombosis in 2.0% and acute coronary syndrome (ACS) in 1.6%. When adjusted by age, sex and risk factors, only HF (Odds ratio (OR) = 7.16; 95% confidence intervals (CI), 3.96-12.92) and ACS (OR = 5.44; 95% CI, 1.50-19.82) were significantly associated with CV history. There was no association with arrhythmias, type 2 acute myocardial infarction, arterial or venous thrombosis. CONCLUSIONS: Patients with a history of CV disease are at greater risk of suffering HF and ACS when hospitalized due to COVID-19. Arrhythmias, type 2 AMI, and arterial or venous thrombosis occur with the same frequency in patients with or without CV history, suggesting that these complications depend on inflammatory phenomena related to the infection.

[Cardiovascular complications in COVID-19 patients admitted to intensive care units in Chilean hospitals]. / Complicaciones cardiovasculares en pacientes COVID-19 hospitalizados en Unidades de Pacientes Críticos en Chile. Registro COVICAR.

BACKGROUND: Patients with a cardiovascular (CV) history may be at greater risk of becoming ill and die due to SARS-CoV-2. AIM: To assess the incidence of CV complications in COVID-19 patients, the type of complication, and their association with CV history. MATERIAL AND METHODS: The clinical course of 1,314 patients with COVID-19 admitted consecutively to critical care units of 10 Chilean hospitals was registered between April and August of 2020. RESULTS: The median age of patients was 59 years and 66% were men. One hundred-four (8%) had a CV history, namely heart failure (HF) in 53 (4.1%), coronary heart disease in 50 (3.8 %), and atrial fibrillation in 36 (2.7 %). There were CV complications in 359 patients (27.3%). The most common were venous thrombosis in 10.7% and arrhythmias in 10.5%, HF in 7.2%, type 2 acute myocardial infarction in 4.2%, arterial thrombosis in 2.0% and acute coronary syndrome (ACS) in 1.6%. When adjusted by age, sex and risk factors, only HF (Odds ratio (OR) = 7.16; 95% confidence intervals (CI), 3.96-12.92) and ACS (OR = 5.44; 95% CI, 1.50-19.82) were significantly associated with CV history. There was no association with arrhythmias, type 2 acute myocardial infarction, arterial or venous thrombosis. CONCLUSIONS: Patients with a history of CV disease are at greater risk of suffering HF and ACS when hospitalized due to COVID-19. Arrhythmias, type 2 AMI, and arterial or venous thrombosis occur with the same frequency in patients with or without CV history, suggesting that these complications depend on inflammatory phenomena related to the infection.

Chronic angina secondary to Takayasu arteritis. Report of one case.

Chronic coronary syndromes are usually considered uncommon in young women, related to slower progression of atherosclerotic coronary artery disease, have atypical clinical presentations, and experience less diagnostic investigation. Non-atherosclerotic causes of coronary artery disease should be considered in young women experiencing angina. We report a 25-year-old woman who consulted for five months of moderate exertion angina. Physical examination revealed a right carotid bruit and asymmetrical upper extremity peripheral pulses. Initial work-up and imaging allowed to diagnose aortitis with bilateral coronary ostial stenosis secondary to Takayasu's arteritis. The patient experienced an apparent clinical response to initial medical therapy. However, follow-up evaluation revealed persistence of significant ischemia and requirement for myocardial revascularization. A percutaneous coronary intervention was performed.

Consequences of COVID-19 pandemic on myocardial infarction reperfusion therapy and prognosis.

Background The coronavirus disease (COVID-19) pandemic affected the prompt diagnosis and treatment of Acute myocardial infarction (AMI). AIM: To characterize the clinical profile of patients with AMI during the COVID-19 pandemic, comparing them with a historical cohort. MATERIAL AND METHODS: A case-control study of 96 patients with AMI transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March and July 2020, and a historical cohort of 269 patients transferred during the same period in 2019. RESULTS: When comparing patients transferred during the pandemic with those of the historical cohort, the former were younger (63 ± 12 vs 68 ± 12 years, p < 0.01), had a higher frequency of hypertension (66 vs 45%, p < 0.01) and of smoking (40% vs 25%, p < 0.01). Also, during COVID-19 outbreak a higher proportion of patients had ST-elevation AMI consulting > 12 hours from the onset of symptoms (44 vs 0%, p < 0.01), a higher median door-to-device time (4 vs 3 hours, p < 0.01), a higher use of primary percutaneous coronary intervention (97 vs 71%, p < 0.01), and higher frequencies of cardiogenic shock (20 vs 4%, p < 0.01) and mechanical complications (10% vs 2%, p < 0.01). Patients during COVID pandemic had a higher thirty-day overall (20 vs 1.4%, p < 0.01) and cardiovascular mortality (13 vs 1%, p < 0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for thirty-day overall mortality (Risk ratio 2.90; 95% confidence intervals 1.14-7.36). CONCLUSIONS: During the pandemic patients with AMI exhibited delays in consultations and treatment, higher morbidity, and increased mortality. COVID-19 positivity was associated to worse thirty-day overall survival.

Consequences of COVID-19 pandemic on myocardial infarction reperfusion therapy and prognosis / Consecuencias de la pandemia COVID-19 en la reperfusión y pronóstico del infarto de miocardio

ABSTRACT Background The coronavirus disease (COVID-19) pandemic affected the prompt diagnosis and treatment of Acute myocardial infarction (AMI). Aim: To characterize the clinical profile of patients with AMI during the COVID-19 pandemic, comparing them with a historical cohort. Material and Methods: A case-control study of 96 patients with AMI transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March and July 2020, and a historical cohort of 269 patients transferred during the same period in 2019. Results: When comparing patients transferred during the pandemic with those of the historical cohort, the former were younger (63 ± 12 vs 68 ± 12 years, p 12 hours from the onset of symptoms (44 vs 0%, p < 0.01), a higher median door-to-device time (4 vs 3 hours, p < 0.01), a higher use of primary percutaneous coronary intervention (97 vs 71%, p < 0.01), and higher frequencies of cardiogenic shock (20 vs 4%, p < 0.01) and mechanical complications (10% vs 2%, p < 0.01). Patients during COVID pandemic had a higher thirty-day overall (20 vs 1.4%, p < 0.01) and cardiovascular mortality (13 vs 1%, p < 0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for thirty-day overall mortality (Risk ratio 2.90; 95% confidence intervals 1.14-7.36). Conclusions: During the pandemic patients with AMI exhibited delays in consultations and treatment, higher morbidity, and increased mortality. COVID-19 positivity was associated to worse thirty-day overall survival.

Antecedentes: La pandemia COVID-19 afectó el tratamiento oportuno del infarto agudo de miocardio (IAM). Objetivo: Caracterizar el perfil clínico de pacientes con IAM durante la pandemia COVID-19 y compararlos con una cohorte histórica. Pacientes y Métodos: Estudio caso-control de 96 pacientes con IAM transferidos a un hospital de alto volumen de intervención coronaria percutánea (ICP) entre marzo julio de 2020 y una cohorte histórica de 269 pacientes transferidos en el mismo período de 2019 (n = 269). Resultados: Al comparar los pacientes transferidos durante pandemia y la cohorte histórica, los primeros eran más jóvenes (63 ± 12 y 68 ± 12 años respectivamente, p 12 h desde iniciados síntomas de IAM con elevación ST (44,4 y 0% respectivamente, p < 0,01), una mediana de tiempo puerta-guía mayor (4 y 3 horas respectivamente, p < 0,01), un mayor uso de ICP primaria (97 y 71% respectivamente, p < 0,01), mayor frecuencia de shock cardiogénico (19,8 y 4,1% respectivamente, p < 0.01) y complicaciones mecánicas (10,4 y 1,7% respectivamente, p < 0,01). A treinta días, los primeros tuvieron mayor mortalidad general (19,8 y 1,4% respectivamente p < 0.01) y cardiovascular (12,5 y 1,4% respectivamente, p < 0,01). Durante la pandemia, 40% de los pacientes presentó positividad para COVID-19, siendo un factor predictivo de mortalidad general (razón de riesgo 2,90; intervalos de confianza 95% 1,14-7,36). Conclusiones: Durante la pandemia, hubo retrasos en tiempos de consulta y tratamiento y mayor morbimortalidad del IAM. La positividad de COVID-19 se asoció a peor sobrevida general a treinta días.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology

ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.

Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico / Myocardial infarction with non-obstructive coronary artery disease. Diagnostic value of intravascular imaging and cardiac resonance

BACKGROUND: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. AIM: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. MATERIAL AND METHODS: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. RESULTS: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. CONCLUSIONS: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

Facial cortical bone regeneration post-extraction in non-grafted sockets allows for early implant placement and long-term functional stability.

OBJECTIVE: To evaluate posterior implant placement feasibility shortly after tooth extraction in non-grafted sockets with and without dehiscence at the time of extraction. DESIGN: Ninety-five patients requiring posterior extractions entered this cross-sectional study. They were divided in three groups after extraction: G1 without dehiscence, G2 with dehiscence ≤5 and G3 > 5 mm. CBCT were taken prior to implant placement at an average of 12-weeks post-extraction to evaluate the need for grafting, cortical bone formation and bucco-lingual width (BLW). Actual BLW (n = 60) were compared to minimum expected BLW in 3 scenarios of BLW thickness averaging 6.4-7.4-8.4 mm. Peri-implant tissues were assessed for pocket formation and inflammation following established success criteria. RESULTS: New cortical bone formation and sufficient BLW made implant placement feasible in sites with and without dehiscence at the time of extraction after an average healing time of 11.9 ± 2.4weeks (range: 8-18). Total average CBCT BLW was 10.1 ± 1.6 mm. All groups had a significantly higher BLW, than scenarios 1-3 (p < 0.0001). Molars were 20 times more likely than premolars to heal with BLW>10 mm (OR = 20; RR = 4.2; CI95 %: 5.3-74.2; p < 0.0001). Dehiscence sockets were 1.5 times more likely than non-dehiscenced sockets to present BLW ≤ 10 mm (OR = 1.5; RR = 0.6; CI95 %:0.9-2.5; p = 0.08). A band of keratinized tissue was present in all implants and success rates were 100 % at an average follow-up of 51.0 ± 23.4 months. CONCLUSION: Implant placement is feasible without socket grafting shortly after tooth extraction. Non-grafted sockets present a significant osteogenic potential. Dehiscence sockets are likely to self-repair by forming a new cortical plate. The unassisted regenerated intra-socket bone allows for functional implant stability long-term.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology.

BACKGROUND: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. AIM: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. MATERIAL AND METHODS: Review of clinical records of seven patients treated between January 2014 and October 2018. RESULTS: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. CONCLUSIONS: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

[Myocardial infarction with non-obstructive coronary artery disease. Diagnostic value of intravascular imaging and cardiac resonance]. / Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico.

BACKGROUND: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. AIM: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. MATERIAL AND METHODS: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. RESULTS: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. CONCLUSIONS: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

Marginal and internal fit of CAD/CAM frameworks in multiple implant-supported restorations: Scanning and milling error analysis.

BACKGROUND: Despite computer-aided design and computer-aided manufacturing (CAD/CAM) technology improving prosthesis fit, errors inherent to digital workflow still exist. PURPOSE: To measure scanning/milling errors, and identify factors influencing marginal (MD) and internal discrepancy (ID). MATERIALS AND METHODS: After scanning, 22 conical abutments in 5 master casts, 6 suprastructures with more than 2 implants (3, 4, and 6) were CAD designed. Angular deviation and errors in the vertical/horizontal planes were analyzed using a coordinate measuring machine (CMM). CAD suprastructures were milled and MD/ID evaluated with micro-computed tomography (CT) and optic microscopy (OM) at one screw test (OST) and final fit test (FFT). RESULTS: Mean scanning errors, at the vertical/horizontal planes, and angulation error were 3 µm ± 13, 44 µm ± 34, 0.3° ± 0.2°, respectively. Angulation errors nearly double in structures >3 abutments (0.26°vs 0.4°). OM MD in FFT/OST was 57.7 µm ± 13.9/100.7 µm ± 34.6, respectively. Micro-CT FFT-MD was 38.9 µm ± 12.8. Lineal/perimetral ID was 49.6 µm ± 11.9 and 108.2° ± 41.8, respectively. Structures >3-implants were 2.3 times more likely to present higher MD (CI95%:0.4-13.6). Nearly all the internal horizontal gap was due to scanning errors (44 of 49.6 µm). Horizontal scanning errors were three times more likely to present greater ID (CI95%:0.5-17.4). CONCLUSION: Horizontal plane scanning errors are greater than vertical errors. Scanning angulation/milling errors are higher for suprastructures>3implants. Scanning/milling errors are associated with ID/MD, respectively, leading to micro-gap formation. A CMM reduces scanning errors in >3-implant-frameworks before milling the final piece.

[Proportion of patients with heart failure in a specialized clinic eligible for novel therapies]. / Pacientes elegibles para las nuevas terapias de la insuficiencia cardíaca en un policlínico especializado.

BACKGROUND: Pharmacological treatment improves survival in patients with heart failure with reduced ejection fraction. The use of sacubutril/valsartan and ivabradine has been recently approved and incorporated in the latest guidelines. AIM: To identify candidates eligible for these therapies among patients treated in a heart failure clinic, considering the inclusion criteria for the PARADIGM-HF and SHIFT trials. MATERIAL AND METHODS: Cross-sectional study on 158 patients aged 62 ± 11 years (67% male) with heart failure and reduced ejection fraction, with at least three months of follow-up and without decompensation. The percentage of patients complying for the inclusion criteria for the PARADIGM-HF y SHIFT trials was determined. RESULTS: In 37%, the etiology of heart failure was ischemic, 49% were in functional class I, their ejection fraction was 33 ± 11% and their median Pro-brain natriuretic peptide was 800 pg/mL. Ninety five percent were treated with vasodilators, 97% with beta-blockers and 82% with aldosterone antagonists. Using PARADIGM-HF and SHIFT criteria, 11 patients (7%) were eligible for sacubitril / valsartan and 21 patients (13.3%) for ivabradine. Among the main causes of non-eligibility for sacubitril / valsartan were being functional class I (48.7%) and not achieving a stable dose of enalapril ≥ 20 mg / day or losartan ≥ 100 mg / day (24.7%). In the case of ivabradine, apart from those in functional class I, the absence of sinus rhythm and a heart rate < 70 / min when receiving a maximal tolerated dose of beta-blockers, were present in 22%. CONCLUSIONS: A low percentage of our patients were eligible for these therapies. Among the causes that explain these results were clinical stability, a high percentage of patients in functional class I and being in a disease modifying treatment.

Influence of mandibular third molar surgical extraction on the periodontal status of adjacent second molars.

BACKGROUND: The periodontal health distal of second molars (M2) is often compromised because of third molar (M3) impactions. The aim of this study was to evaluate healing and periodontal status of mandibular M2 after M3 surgical extraction. METHODS: Eighty-nine consecutive patients with 89 asymptomatic M3 who needed surgical extraction of one fully- or semi-impacted M3 entered this study. Clinical measurements, probing pocket depth (PPD), clinical attachment level (CAL), plaque index (PI), gingival index (GI), and bleeding on probing (BOP), were compared for M2 at baseline (T0) and 6-months (T1) postsurgical extraction. Multiple logistic regression analysis assessed different risk factors for postoperative changes of periodontal parameters. RESULTS: Six-month M2 PPD improved at disto-vestibular (T0-5.2/T1-3.0 mm) and disto-lingual (T0-5.4/T1-3.2 mm) sites. The average attachment gains at T1 were 1.9 and 2 mm, respectively (P < 0.05). BOP, PI, and GI showed significant clinical improvements after extractions. Fifty-three out of 72 (73.6%) M2 presenting a PPD ≥ 4mm at baseline healed at 6 months recall without periodontal pockets. Older age (mean 55 years, SD 16.7; range 26 to 81) and mean distal PPD at baseline of 7 mm was more likely to be associated with PPD ≥ 4 mm 6 months postextraction (P < 0.05). Past history of periodontitis patients were 41 times more likely to present PPD ≥ 4 mm after healing (OR = 41.4; 95% CI = 10.9 to 156.5, P < 0.05). CONCLUSION: Mandibular M3 extractions seem to improve overall periodontal health distal of M2. History of periodontitis, preoperative deep pockets and older age are independent risk factors for poorer healing and residual pockets after M3 surgical extraction.