[Elective primary angioplasty in cardiogenic shock: results from a single center]. / Angioplastia primaria electiva en el shock cardiogénico: resultados de un estudio unicéntrico.

INTRODUCTION: Cardiogenic shock is the leading cause of death among patients hospitalized for acute myocardial infarction. Conventional treatment for acute myocardial infarction does not achieve a better outcome in these patients, but prior studies with emergency revascularization by coronary angioplasty seem to provide encouraging results. PATIENTS AND METHOD: A retrospective study of the clinical and angiographic results of elective primary angioplasty in 48 patients with cardiogenic shock complicating acute myocardial infarction of less than 12 hours is described. Intraaortic balloon counterpulsation was used in 79% of the patients. Patients with cardiogenic shock secondary to mechanical complications were excluded. RESULTS: Angiographic success, defined as a residual stenosis < 50% and final TIMI flow >/= 2, was achieved in 85% of the culprit lesions, and stents were implanted in 76%. Multivessel angioplasty was performed in 25% of the patients, and abciximab was used in 35% of the cases. Mean time from the onset of symptoms to angioplasty was 7.4 +/- 3.1 hours. In-hospital survival was 58%, and was 54% at six months follow-up. CONCLUSIONS: Emergency coronary revascularization with primary angioplasty and intracoronary stenting is effective in patients with acute myocardial infarction and cardiogenic shock. TIMI flow >/= 2 is achieved in most patients, and mortality is reduced when compared with conservative treatment in historical series.

[Immediate hemodynamic response to atrioventricular+ stimulation in severe hypertrophic obstructive myocardiopathy]. / Respuesta hemodinámica inmediata a la estimulación bicameral en la miocardiopatía hipertrófica obstructiva severa.

INTRODUCTION AND OBJECTIVES: Atrial synchronized ventricular pacing has shown to be an alternative to surgery in the therapeutic management of obstructive hypertrophic cardiomyopathy. Our purpose is the analysis of the hemodynamic mechanisms associated with the reduction of left ventricular outflow tract gradient and the changes in left ventricular diastolic function induced by dual-chamber pacing. PATIENTS AND METHODS: We studied twenty patients (age range 40-78 years; mean 63 +/- 10), who were evaluated while receiving their current medication with cardiac catheterization and angiography, at baseline and under dual-chamber pacing. RESULTS: The atrioventricular delay was 127 +/- 26 ms. The subaortic gradient was reduced from 96 +/- 38 to 36 +/- 28 mmHg (p < 0.001), the ejection period index was shortened from 523 +/- 26 to 491 +/- 30 ms (p < 0.001) and the left ventricular end-diastolic pressure fell from 22 +/- 6 to 13 +/- 5 mmHg (p < 0.001). There was no remarkable change in cardiac output. The median wedge pressure decreased from 17 +/- 5 to 12 +/- 2.5 mmHg (p < 0.01), the pulmonary systolic pressure from 39 +/- 15 to 30 +/- 10 mmHg (p < 0.01), the pulmonary diastolic pressure from 19 +/- 5 to 13 +/- 4 mmHg (p < 0.01) and the right ventricular end-diastolic pressure from 7 +/- 3 to 5 +/- 3 mmHg (p < 0.05). The left ventricular ejection fraction was reduced from 79 +/- 6 to 72 +/- 6 per cent (p < 0.001). The initial ejection fraction diminished from 49 +/- 13 to 34 +/- 13 per cent (p < 0.01), the early diastolic filling increased from 39 +/- 11 to 52 +/- 10 per cent (p < 0.001) and the atrial contribution was reduced from 36 +/- 10 to 24 +/- 10 per cent (p < 0,001). The degree of mitral regurgitation changed from 1.4 +/- 1.2 to 0.7 +/- 0.9 (p < 0.01). CONCLUSIONS: There is an obstruction in the left ventricular outflow tract in patients with obstructive hypertrophic cardiomyopathy that is relieved with dual-chamber pacing. The reduction in the intraventricular pressure seems to improve the ventricular relaxation and the diastolic function. The decrease in the degree of mitral regurgitation and the improvement in diastolic function diminish pulmonary capillary and right circuit pressures.

[Analysis of hemodynamics costs. A multicenter study based on consumed resources]. / Análisis de costes de hemodinámica. Estudio multicéntrico basado en consumos reales.

INTRODUCTION AND OBJECTIVES: The main objective of this study is to know actual hemodynamic explorations costs in Spain, not only direct but total imputation costs, through a registration of duration, resources and disposables used in this minimally invasive exploration. Also to explore the variability in costs and consumptions between hospitals with similar technology in catheterization practice. METHODS: The effective duration, supplies consumptions and manpower resources utilized in 762 diagnostic catheterization, 217 therapeutic coronarographies, and 32 Inoue mitral valvotomies have been registered and analyzed in four public Spanish hospitals. The direct costs have been calculated through purchase and repair bills and officials wages. The indirect ones through repercussion judgements, and the amortization on a ten years imputation process. RESULTS: The consumption, duration and manpower data are shown with media and standard deviations. Final costs are: 106,879 pesetas for a diagnostic catheterization, 545,614 pesetas for a therapeutic coronarography, and 556,315 pesetas for a mitral Inoue valvotomy. Significative differences have been demonstrated between hospitals affecting the majority of consumption and manpower variables. There are also wide differences on indirect costs, amortization and maintenance costs. CONCLUSIONS: The catheterization costs are high in Spain mainly due to disposable material costs in spite of low manpower costs in public hospitals. The indirect administration costs are of relative importance in diagnostic catheterization, but in the therapeutic ones the only important payment are the disposable material costs who get the 85% of total cost. The differences between hospitals in durations and consumptions show the need to improve medical protocols. The differences in indirect costs reflect different steps in implementation of hospital management tools.