[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.

[Demonstrated myocardial ischemia due to multiple coronary fistulae draining into the left ventricle]. / Isquemia miocárdica demostrada secundaria a fístulas coronarias múltiples con drenaje en el ventrículo izquierdo.

There are few cases of demonstrated ischemia due to the presence of multiple coronary fistulae. We report a case of multiple coronary fistulae from left anterior descending, circumflex and right coronary arteries draining into the left ventricle, which were responsible for myocardial ischemia demonstrated with thallium stress test. They were diagnosed by coronary angiography, and their etiology seems to be congenital. The final control of symptoms was achieved with beta-blockers, and not with nitrates, which speaks for a steal phenomenon as the cause of ischemia.

[Hybrid revascularization]. / Revascularización híbrida.

OBJECTIVE: To evaluate our initial experience in the combination of two less invasive procedures for myocardial revascularization, coronary artery bypass grafting without cardiopulmonary bypass and immediate posterior angioplasty, on untreated lesions (hybrid revascularization) as an alternative treatment to conventional surgery in selected patients. MATERIAL AND METHODS: From october 1996 to September 1998, 19 patients received hybrid revascularization. The mean age was 64 (47-76). Two patients underwent urgent surgery. Two patients had left main coronary disease, and 9 three-vessel disease. In general, we considered this procedure for patients with high-risk factors for cardiopulmonary bypass and two or more vessel disease. The internal mammary artery was connected to the left anterior descending artery in all 19 patients. All patients were moved to the hemodynamic ward immediately after surgery in 7 cases and before 48 h in the rest, 24 angioplasties were performed. A mean of 2.6 vessels per patient were revascularized and revascularization was complete in 15 patients (79%). RESULTS: One patient had perioperative myocardial infarction. There was no hospital mortality. Length of stay in the intensive care unit was 44 h (IQR = 49) and global postoperative stay was 8 days (IQR = 3.5). In the postoperative angiographic study, before the angioplasty, 95% of mammary arteries (CI 95% 74-100%) and 100% of saphenous grafts (CI 95% 59-100%) were patent. CONCLUSIONS: Combined revascularization allows almost complete revascularization, avoiding complications of cardiopulmonary bypass and minimizing surgical aggression. At the same time, it secures the graft of internal mammary artery to left anterior descending artery.

[The therapeutic focus in severe hypertrophic obstructive cardiomyopathy with multivessel coronary disease]. / Enfoque terapéutico en la miocardiopatía hipertrófica obstructiva severa con enfermedad coronaria multivaso.

The association of severe hypertrophic obstructive cardiomyopathy and coronary artery disease increases surgical morbimortality, even more in patients over 65 years. We describe a combined therapeutic approach to these diseases. A 68-year-old woman with a diagnosis of hypertrophic obstructive cardiomyopathy was in functional class IV for angina and dyspnea despite 360 mg of propranolol a day. An echocardiogram and a complete cardiac catheterization were performed under betablocker therapy, confirming a severe hypertrophic obstructive cardiomyopathy and revealing severe stenosis in the proximal left circumflex and the proximal right coronary arteries, and a moderate lesion in the mid-left anterior descendent. They were both treated with balloon PTCA, and a 3 x 15 mm stent was placed in the circumflex and a 3.5 x 20 mm stent in the right coronary, with an excellent angiographic result. A basal hemodynamic study was then performed and A-V sequential pacing was attempted, achieving a significant decrease in the left ventricle outflow tract gradient. A DDD-R pacemaker was implanted. Echocardiographic study was performed post-implantation, and follow-up was made six months later with a new coronary angiography, hemodynamic study and a Doppler echocardiogram. At the present time A-V sequential pacing as a therapeutic option for hypertrophic obstructive cardiomyopathy and coronary angioplasty and stenting for the treatment of coronary artery disease are sufficiently established and supported to be offered as a combined therapy to patients suffering from both diseases, specially those with a higher surgical risk.

[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.