Ectasia coronaria y lesiones trombóticas como causa de síndrome coronario agudo / Coronary ectasia and thrombotic injuries as a cause of acute coronary syndrome

Resumen Se presenta un caso de manejo complicado y decisiones difíciles. Un paciente con antecedente de disección aórtica tipo A y dilatación residual de la aorta descendente de hasta 60 mm es ingresado por un síndrome coronario agudo sin elevación del ST. La coronariografía pone de manifiesto una marcada ectasia coronaria y unos defectos de perfusión de dudoso origen. ¿Trombos o falsas imágenes por flujo muy lentificado? Asumiendo que pudiera tratarse de trombos, el paciente es tratado con anticoagulación repitiéndose la coronariografía al cabo de dos meses. En este segundo estudio se observa la completa desaparición de las imágenes, confirmándose el origen trombótico de las mismas. En este momento se plantea ¿cuál debe ser el tratamiento crónico del paciente? No hay evidencia científica disponible acerca del tratamiento de la ectasia coronaria y se trata de un paciente de alto riesgo por su antecedente de disección aórtica. Finalmente se decide, de forma empírica, mantener la anticoagulación de forma indefinida. Tras dos años y seis meses de seguimiento no ha habido incidencias clínicas.

Abstract A case with complicated management and difficult decision-making is presented. A patient with history of type A aortic dissection and residual dilatation of the descending aorta up to 60 mm is admitted for acute coronary syndrome without ST elevation. Coronary angiography reveals a marked coronary ectasia and perfusion defects of unclear origin. Thrombosis or fake images due to flow reduction? Assuming that it could be caused by thrombosis the patient is treated with anticoagulant therapy and the coronary angiography is repeated after two months. This second study shows complete clearing of imaging findings, confirming the thrombotic origin. At this stage considerations are taken so as to plan a chronic treatment for the patient? There is no scientific evidence regarding the treatment for coronary ectasia and this is a high-risk patient because of his aortic dissection history. Finally it is empirically decided to indefinitely keep anticoagulant therapy. After two years and six months of follow-up there has been no clinical incidents.

Prevalence of atrial fibrillation in Spain. OFRECE study results.

INTRODUCTION AND OBJECTIVES: Atrial fibrillation is associated with substantial morbidity and mortality and both its incidence and prevalence are high. Nevertheless, comprehensive data on this condition in Spain are lacking. The aim of this study was to estimate the prevalence of atrial fibrillation in Spain. METHODS: A cross-sectional study was conducted in the general Spanish population older than 40 years. Two-stage random sampling was used, in which first-stage units were primary care physicians randomly selected in every Spanish province and second-stage units were 20 randomly selected persons drawn from each participating physician's assigned population. The reported prevalence was standardized for the age and sex distribution of the Spanish population. The electrocardiogram recordings were read centrally. RESULTS: Overall, 8343 individuals were evaluated. The mean age was 59.2 years (95% confidence interval, 58.6-59.8 years), and 52.4% of the participants were female. The overall age-adjusted prevalence of atrial fibrillation was 4.4% (95% confidence interval, 3.8-5.1). Prevalence was similar in both sexes, men 4.4% (3.6-5.2) and women 4.5% (3.6-5.3), rising with increasing age older than 60 years. In patients older than 80 years, the prevalence was 17.7% (14.1-21.3). In 10% of patients an unknown atrial fibrillation was diagnosed. CONCLUSIONS: The prevalence of atrial fibrillation in the general Spanish population older than 40 years is high, at 4.4%. The prevalence is similar in both sexes and rises steeply above 60 years of age. It is estimated that there are over 1 million patients with atrial fibrillation in the Spanish population, of whom over 90,000 are undiagnosed.

Prevalencia de fibrilación auricular en España. Resultados del estudio OFRECE / Prevalence of Atrial Fibrillation in Spain. OFRECE Study Results

Introducción y objetivos: La fibrilación auricular se asocia con elevadas morbilidad y mortalidad, y tanto su incidencia como su prevalencia son altas. No obstante, hay escasos datos poblacionales sobre su epidemiología en España. El objetivo de este estudio es estimar la prevalencia de fibrilación auricular en España. Métodos: Estudio transversal en población española de 40 o más años. Se realizó un muestreo en dos etapas, una primera selección aleatoria de médicos de atención primaria de cada provincia española y, en segundo lugar, se seleccionó aleatoriamente a 20 individuos de la población asignada a cada médico participante. La prevalencia se ponderó por edad, sexo y área geográfica. Se realizó una lectura centralizada de los registros electrocardiográficos. Resultados: Se evaluó a 8.343 personas (media de edad, 59,2 [intervalo de confianza del 95%, 58,6-59,8] años; el 52,4% mujeres). La prevalencia total de fibrilación auricular fue del 4,4% (intervalo de confianza del 95%, 3,8-5,1). La prevalencia fue similar en varones (4,4% [3,6-5,2]) y mujeres (4,5% [3,6-5,3]) y se incrementa progresivamente a partir de los 60 años de edad. En los mayores de 80 años, la prevalencia fue del 17,7% (14,1-21,3). En un 10% de pacientes se diagnosticó una fibrilación auricular no conocida. Conclusiones: La prevalencia de fibrilación auricular en la población general española mayor de 40 años es elevada, del 4,4%. La prevalencia es similar en varones y mujeres y se incrementa escalonadamente a partir de los 60 años. Se estima en más de 1 millón de pacientes con fibrilación auricular en la población española, de los que más de 90.000 están sin diagnosticar (AU)

Introduction and objectives: Atrial fibrillation is associated with substantial morbidity and mortality and both its incidence and prevalence are high. Nevertheless, comprehensive data on this condition in Spain are lacking. The aim of this study was to estimate the prevalence of atrial fibrillation in Spain. Methods: A cross-sectional study was conducted in the general Spanish population older than 40 years. Two-stage random sampling was used, in which first-stage units were primary care physicians randomly selected in every Spanish province and second-stage units were 20 randomly selected persons drawn from each participating physician's assigned population. The reported prevalence was standardized for the age and sex distribution of the Spanish population. The electrocardiogram recordings were read centrally. Results: Overall, 8343 individuals were evaluated. The mean age was 59.2 years (95% confidence interval, 58.6-59.8 years), and 52.4% of the participants were female. The overall age-adjusted prevalence of atrial fibrillation was 4.4% (95% confidence interval, 3.8-5.1). Prevalence was similar in both sexes, men 4.4% (3.6-5.2) and women 4.5% (3.6-5.3), rising with increasing age older than 60 years. In patients older than 80 years, the prevalence was 17.7% (14.1-21.3). In 10% of patients an unknown atrial fibrillation was diagnosed. Conclusions: The prevalence of atrial fibrillation in the general Spanish population older than 40 years is high, at 4.4%. The prevalence is similar in both sexes and rises steeply above 60 years of age. It is estimated that there are over 1 million patients with atrial fibrillation in the Spanish population, of whom over 90 000 are undiagnosed (AU)

Atrial activation occurring immediately after successful cardioversion of atrial fibrillation.

BACKGROUND AND OBJECTIVE: Electrical defibrillation is very effective in interrupting atrial fibrillation (AF). However, its mechanism is not completely understood. We report our observations in patients subjected to external electriocardioversion (ECV) of atrial fibrillation and contrast them with recent theories about defibrillation mechanism. METHODS: In 13 consecutive patients transthoracic electrical cardioversion for AF was performed during an electrophysiological study (11 monophasic -200-360 J- and 9 biphasic shocks -50-150 J-). About 10-16 electrograms were obtained with multipolar catheters recording right atrium, coronary sinus, and right pulmonary artery. AF was defined by interelectrogram intervals and changing sequences among recordings, indicating complete lack of organization. We evaluated the presence of propagated activations immediately (<300 ms) after successful shocks (>or=1 discrete electrogram in all recordings). In unsuccessful shocks we evaluated changes in electrogram morphology (discrete/fragmented) and interelectrogram intervals before and after defibrillation. RESULTS: About 16/20 shocks terminated AF. In 6/16 one or two cycles of atrial activation were recorded just after the shock and before AF ended. In 10/16 AF was interrupted immediately after the shock. 4/20 shocks did not interrupt the arrhythmia. After these shocks, transient organization of recorded activity with longer interelectrogram cycle length and disappearance of fragmented activity were transiently observed. CONCLUSION: Our clinical findings in atrial defibrillation in vivo reproduce experimental data that show myocardial activations early after successful direct current shocks. These observations suggest that successful defibrillation depends not only on the immediate effects of the shock, but also on transient effects on electrophysiological properties of the myocardium, capable of interrupting persistent or reinitiated activations.

Left atrium myxosarcoma: an exceptional cardiac malignant primary tumor.

We report the case of a 32-year-old patient with a left atrium myxosarcoma, presenting with congestive heart failure. It is a rare cardiac malignant primary tumor that seems to derive from the same cellular line as myxomas, but the prognosis is very different. These tumors present local recidives and distance metastasis, so the mean survival is about 1 year, independent of any therapeutical option.

[The superior vena cava as a site of ectopic foci in atrial fibrillation]. / La vena cava superior como inductora de fibrilación auricular de origen focal.

Radiofrequency catheter ablation of ectopic foci that trigger atrial fibrillation has been established as a curative method for patients with symptomatic paroxysmal atrial fibrillation. Although the majority of these foci are located in and around the pulmonary veins, other less common locations have been identified. Recognition that foci can lie outside the pulmonary veins is important for ensuring therapeutic success. The most frequently reported foci of ectopic activity outside the pulmonary veins are in the superior vena cava and the posterior wall of the left atrium. Here we report our experience with the ablation of ectopic foci located in the superior vena cava in patients with symptomatic paroxysmal atrial fibrillation.

La vena cava superior como inductora de fibrilación auricular de origen focal / The superior vena cava as a site of ectopic foci in atrial fibrillation

La ablación de focos auriculares precipitantes de fibrilación auricular se ha constituido como una técnica curativa para pacientes con fibrilación auricular paroxística sintomática. Aunque la mayoría de focos ha sido descrita en las venas pulmonares, se han identificado otras localizaciones que, aunque menos frecuentes, pueden ser de relevancia clínica en determinados pacientes. El reconocimiento de estas localizaciones durante un procedimiento de ablación es fundamental a la hora de planear el abordaje anatómico. La vena cava superior, junto con la pared posterior de la aurícula izquierda, suele ser la localización más frecuente de actividad ectópica fuera de las venas pulmonares. Presentamos nuestra experiencia de la ablación de focos ectópicos en la vena cava superior en pacientes con fibrilación auricular paroxística sintomática

Radiofrequency catheter ablation of ectopic foci that trigger atrial fibrillation has been established as a curative method for patients with symptomatic paroxysmal atrial fibrillation. Although the majority of these foci are located in and around the pulmonary veins, other less common locations have been identified. Recognition that foci can lie outside the pulmonary veins is important for ensuring therapeutic success. The most frequently reported foci of ectopic activity outside the pulmonary veins are in the superior vena cava and the posterior wall of the left atrium. Here we report our experience with the ablation of ectopic foci located in the superior vena cava in patients with symptomatic paroxysmal atrial fibrillation

[Atrial flutter: an update]. / Flúter auricular: perspectiva clínica actual.

Invasive electrophysiologic studies have changed the clinical outlook for patients with atrial flutter. Recognition of the reentrant circuit responsible for typical atrial flutter has led to the development of catheter ablation techniques that can prevent recurrence in >90% of cases. In addition, general understanding of atrial tachycardias has changed radically, such that ECG-based classifications are now obsolete. Atypical reentrant circuits associated with surgical scars or fibrotic areas in either atrium, which are indistinguishable from focal tachycardias on ECG, have been identified. These circuits also seem amenable to treatment by ablation. Recently, a new type of reentrant tachycardia that could be problematic in the future has emerged in patients who have undergone extensive left atrial ablation for the treatment of atrial fibrillation. These atypical circuits can be characterized using the mapping and entrainment techniques initially developed for typical flutter. In these cases, electroanatomical mapping, involving the construction of a virtual anatomical model of the atria, is extremely helpful. Despite the success of ablation, long-term prognosis is frequently overshadowed by the appearance of atrial fibrillation, which suggests that flutter and fibrillation share a common arrhythmogenic origin that is not modified by cavotricuspid isthmus ablation. In contrast with our clear electrophysiologic understanding of atrial flutter, little is known about the natural history of the condition because the literature has traditionally grouped patients with flutter and fibrillation together. Consequently, the complex relationship between the two arrhythmias has still to be clearly delineated. Primary prevention and preventing the development of atrial fibrillation after ablation remain outstanding clinical challenges.

Flúter auricular: perspectiva clínica actual / Atrial Flutter: an Update

Los estudios electrofisiológicos invasivos han cambiado la perspectiva clínica de los pacientes con flúter auricular. El conocimiento de la estructura del circuito de flúter típico ha permitido desarrollar técnicas de ablación con catéter que eliminan las recidivas en > 90% de los casos. También ha cambiado el concepto global de las taquicardias auriculares, lo que ha hecho obsoletas las clasificaciones basadas en el electrocardiograma. Se han demostrado circuitos reentrantes atípicos basados en cicatrices quirúrgicas o en zonas fibróticas en ambas aurículas, que son también asequibles a tratamiento por ablación y que en el electrocardiograma son indistinguibles de una taquicardia focal. La ablación amplia de la aurícula izquierda para el tratamiento de la fibrilación auricular está dando lugar a un nuevo tipo de taquicardias reentrantes que puede ser problemático en el futuro. Las técnicas de mapeo y encarrilamiento de los circuitos descritas inicialmente en el flúter permiten definir estos circuitos. El mapeo electroanatómico, que construye moldes anatómicos virtuales de las aurículas, es de gran ayuda en estos casos. A pesar del éxito de la ablación, el pronóstico a largo plazo se ensombrece con frecuencia por la aparición de fibrilación auricular, lo que indica que hay un sustrato arritmogénico común al flúter y la fibrilación, que la ablación del istmo cavotricuspídeo no cambia. En contraste con la clara definición electrofisiológica, hay escasa información sobre el curso clínico del flúter, ya que tradicionalmente la bibliografía se refiere a grupos de «flúter y fibrilación auricular» y las complejas relaciones entre ambas arritmias quedan aún por revelar claramente. La prevención primaria y la prevención de la aparición de fibrilación auricular tras la ablación son retos pendientes (AU)

Invasive electrophysiologic studies have changed the clinical outlook for patients with atrial flutter. Recognition of the reentrant circuit responsible for typical atrial flutter has led to the development of catheter ablation techniques that can prevent recurrence in >90% of cases. In addition, general understanding of atrial tachycardias has changed radically, such that ECG-based classifications are now obsolete. Atypical reentrant circuits associated with surgical scars or fibrotic areas in either atrium, which are indistinguishable from focal tachycardias on ECG, have been identified. These circuits also seem amenable to treatment by ablation. Recently, a new type of reentrant tachycardia that could be problematic in the future has emerged in patients who have undergone extensive left atrial ablation for the treatment of atrial fibrillation. These atypical circuits can be characterized using the mapping and entrainment techniques initially developed for typical flutter. In these cases, electroanatomical mapping, involving the construction of a virtual anatomical model of the atria, is extremely helpful. Despite the success of ablation, long-term prognosis is frequently overshadowed by the appearance of atrial fibrillation, which suggests that flutter and fibrillation share a common arrhythmogenic origin that is not modified by cavotricuspid isthmus ablation. In contrast with our clear electrophysiologic understanding of atrial flutter, little is known about the natural history of the condition because the literature has traditionally grouped patients with flutter and fibrillation together. Consequently, the complex relationship between the two arrhythmias has still to be clearly delineated. Primary prevention and preventing the development of atrial fibrillation after ablation remain outstanding clinical challenges (AU)

Free-floating left atrial thrombus complicating mitral stenosis.

Free-floating thrombus is a rare disorder that usually occurs in the setting of a dilated left atrium. It is an important condition because it can produce sudden death by obstructing the mitral orifice or cause embolic events. Early diagnosis and surgical treatment are mandatory.