Caracterización de la enfermedad estenooclusiva aortoiliaca / Characterization of the stenocclusive aortoiliac disease

Introducción: La enfermedad arterial periférica, específicamente del sector aortoiliaco, es multifactorial, tiene como causa principal la ateroesclerosis obliterante. Las manifestaciones clínicas son variables y la claudicación intermitente es la más frecuente, por lo que es subdiagnosticada. Objetivo: Caracterizar los pacientes con enfermedad estenoclusiva aortoiliaca Métodos: Estudio observacional descriptivo retrospectivo de corte transversal en 86 pacientes ingresados mayores de 18 años de edad con enfermedad estenoclusiva aortoiliaca. Las variables incluidas fueron: edad, sexo, factores de riesgo, clasificación de Fontaine, índice de presiones, patrón por angiografía, conducta, tipos de cirugía vascular, complicaciones, evolución, letalidad quirúrgica global. Fueron atendidos en el hospital Universitario "Calixto García Iñiguez" entre los años 2015 y 2018. Resultados: Se encontró que 72 por ciento de los pacientes era mayor de 60 años y 67,4 por ciento eran hombres. Los factores de riesgo más frecuentes fueron el tabaquismo (73,9 por ciento) y la hipertensión arterial (74,4 por ciento); 34,8 por ciento presentó dolor en reposo y 41,8 por ciento lesiones. El 83,8 por ciento tuvo un índice tobillo brazo menor o igual a 0,4. El 52,4 por ciento clasificó en Darling tipo III. Se revascularizaron 27 casos y 44,2 por ciento tuvo una amputación primaria. Se complicaron 27,6 por ciento y la evolución fue favorable en 54,7 por ciento. La letalidad quirúrgica global fue de 3,03 por ciento. Conclusiones: Se observó que los hombres mayores de 60 años con factores de riesgos eran más propensos a padecer una enfermedad arterial periférica. Se obtuvo una evolución favorable en la mayoría de los casos con un bajo índice de letalidad quirúrgica global(AU)

Introduction: Peripheral arterial disease, specifically in the aortoiliac sector, is multifactorial. It has as main cause the obliterating atheroesclerosis, and the clinical manifestations are changeable and the intermittent claudication is the most frequent, that is why it is underdiagnosed. Objective: To characterize the patients with stenocclusive aortoiliac disease. Methods: Descriptive observational, retrospective and cross-sectional study in 86 patients admitted in hospital, all of them over 18 years old with stenocclusive aortoiliac disease. The variables included were: age, sex, risk factors, Fontaine classification, index of pressures, angiography pattern, behaviour, types of vascular surgery, complications, evolution, and overall surgical lethality. The patients were attended in "Calixto García Iñiguez" University Hospital from 2015 to 2018. Results: It was found that 72.0 percent of the patients were older than 60 years and the 67.4 percent were men. The most frequent risk factors were the smoking habit (73.9 percent) and hypertension (74.4 percent); 34.8 percent presented pain in rest and 41.8 percent presented lesions. The 83.8 percent had an anklebrachial index lower or equal to 0.4. The 52.4 percent classified as Darling type III. There were 27 patients under revascularization and 44.2 percent had a primary amputation. The 27.6 percent of the cases had complications and the evolution was favourable in the 54.7 percent. The overall surgical lethality was of 3.03 percent. Conclusions: It is observed that men over 60 years old with risk factors were proner to suffer from peripheral arterial disease. It was achieved a favourable evolution in most of the cases with a low index of overall surgical lethality(AU)

Úlcera del pie diabético tratado con Heberprot-p® / Diabetic foot ulcer treated with Heberprot-P®

Introducción: La diabetes mellitus cada año aumenta su incidencia, entre los casos diagnosticados y los no diagnosticados a nivel mundial. Debido a que esta trae como consecuencia un daño neuropático y vascular, están consideradas las úlceras del pie diabético la principal causa de amputaciones no traumáticas. El tratamiento oportuno con Heberprot-P® ha mejorado la cicatrización de estas úlceras. Objetivo: Caracterizar los pacientes con úlcera del pie diabético tratado con Heberprot-P®. Métodos: Estudio descriptivo retrospectivo en 312 individuos con diagnóstico de úlcera del pie diabético tratados con Heberprot-P® en el Hospital Universitario Clínicoquirúrgico Docente "General Calixto García Iñiguez" del 2013 al 2017. Las variables recogidas fueron edad, sexo, tipo de diabetes, Wagner, daño vascular, dosis, evolución. Resultados: El 79,7 por ciento de los casos tenían 50 años o más; predominaron los hombres con el 63,4 por ciento y presentaron diagnóstico de diabetes mellitus tipo 2 el 93,6 por ciento. El 35 por ciento de las úlceras se encontraban en el grado 3 de la clasificación de Wagner y el rango de dosis utilizado con más frecuencia fue de 5 a 10 administraciones. Se observó daño vascular en el 23,8 por ciento, con la cicatrización total del 76,6 por ciento y solo se amputaron el 8,9 por ciento. Conclusiones: Los hombres mayores de 50 años, diabéticos tipo 2, con frecuencia presentan úlcera del pie diabético. Cicatrizaron la mayoría de los pacientes con tratamiento con Heberprot-P® y existieron pocas amputaciones(AU)

Introduction: Diabetes mellitus each year increases its incidence among the diagnosed and undiagnosed cases at the global level. Since this disease brings as a consequence a neuropathic and vascular damage, diabetic foot ulcers are considered to be the main cause of non-traumatic amputations. Prompt treatment with Heberprot-P® has improved the healing of these ulcers. Objective: To characterize patients with diabetic foot ulcer treated with Heberprot-P®. Methods: Retrospective descriptive study in 312 individuals diagnosed with diabetic foot ulcer treated with Heberprot-P® in "General Calixto García Iñiguez" University-Teaching- Clinical-Surgical Hospital from 2013 to 2017. The variables collected were: age, sex, type of diabetes, Wagner, vascular damage, dosage, evolution. Results: 79.7 percent of the cases were 50 or more years old; men predominated being the 63.4 percent and 93.6 percent presented diagnosis of diabetes mellitus type 2. The 35 percent of the ulcers were in stage 3 of Wagner classification and the most frequently dose range used was 5 to 10 dosages. Vascular damage was observed in the 23.8 percent, with 76.6 percent of total healing and only the 8.9 percent were amputated. Conclusions: Men over 50 years old being type 2 diabetics present with frecuency diabetic foot ulcer. The majority of patients treated with Heberprot-P® healed and there were few amputations(AU)

Racial and ethnic healthcare disparities in patients undergoing laser lead extraction.

BACKGROUND: The rate of cardiovascular implantable electronic device infections (CIEDIs) has mirrored or exceeded the increased use of implantable cardiac devices in the United States. The presence of racial and ethnic disparities associated with CIEDIs has not been published. Our aim is to describe the presence of racial and ethnic disparities with respect to the management of CIEDIs. METHODS: We reviewed a prospective single-center registry for patients undergoing removal of an implantable cardiac device between 1/2004 and 1/2016. 1173 consecutive patients underwent device extraction. 699 patients were identified as having an infection, 305 were identified as Caucasian and 394 were minorities (91 African Americans, 303 Hispanics). Patients had pre-operative transesophageal echocardiograms (TEEs) and collection of blood and exudate cultures. All underwent complete hardware extraction; leads were removed through the use of locking stylets and traction or laser extraction. En-bloc capsulectomy was performed with intraoperative specimen collection from pocket tissue, exudate, lead tips, and vegetations. RESULTS: Minority patients were: younger (67.9 ±â€¯14.5 years vs 72.4 ±â€¯13.2 years), had a higher proportion of male gender, diabetes, and chronic renal failure (p < 0.001). Minorities experienced a higher rate of complications during extraction and a longer hospitalization (15.3 ±â€¯9.9 days versus 17.4 ±â€¯13.4 days, p < 0.001). There was no significant difference between the proportion of types of infection in both groups. CONCLUSION: Minority patients with CIEDIs experienced more procedural complications during extraction and had a significantly longer length of index hospitalization than Caucasian patients.

Características del paciente con pie diabético no isquémico tratado con Heberprot-p® / Characterization of the patient with non-ischemic diabetic foot treated with Heberprot-P®

Introducción: La diabetes mellitus es una enfermedad que cada año aumenta su incidencia, así como sus complicaciones. El pie diabético es una de las más temidas debido a las características de la enfermedad y el daño vascular que presenta. El Heberprot-P® es un medicamento novedoso y único para el tratamiento de esta complicación, su uso oportuno es importante para salvar la extremidad. Objetivo: Describir las características de los pacientes con pie diabético no isquémico tratados con Heberprot-P®. Métodos: Se realizó un estudio descriptivo retrospectivo en 151 pacientes con pie diabético no isquémico tratados con Heberprot-P ® en el Hospital General Calixto García durante el 2013 y 2014. Las variables estudiadas fueron edad, sexo, tipo de diabetes, localización, reacciones adversas, características de la lesión y desenlace. Resultados: Se encontró que el 49,7 por ciento de los pacientes eran mayores de 60 años el 59,6 por ciento hombres y el 92 por ciento padecía de diabetes mellitus de tipo 2. La localización de la lesión fue más frecuente en los dedos de los pies (33,8 por ciento). El 21,1 por ciento tuvo alguna reacción adversa donde la más frecuente fueron los escalofríos. Los grados de Wagner que más casos presentaron fueron el 2 (31,1 por ciento) y el 3 (32,4 por ciento); las lesiones cicatrizaron en el 84,1 por ciento y se amputó el 2,6 por ciento del total de pacientes. Conclusiones: Se observó que los hombres diabéticos de tipo 2, mayores de 60 años son los más propensos a padecer la enfermedad, presentan pocas reacciones adversas, elevada frecuencia de curación y pocas amputaciones(AU)

Introduction: Diabetes mellitus is a disease whose incidence and complications annually increase. Diabetic foot is one of the most fearful complications due to its characteristics and the vascular damage that occurs. The Heberprot-P is a novel and unique drug for the treatment of this complication. Timely and appropriate use is important for limb salvage.nObjective: To describe the characteristics of patients with non ischemic diabetic foot treated with Heberprot-P. Methods: Retrospective, descriptive and observational study conducted in 151 patients with non-ischemic diabetic foot treated with Heberprot-P ® in General Calixto García hospital in 2013 and 2014. The collected variables were age, sex, location, side effects, injury characteristics and outcomes. Results: We found that 49.6 percent of patients were over 60 years of age, 59.6 percent were men and 92 percent who suffered from type 2 diabetes mellitus. The most frequent location was the toes (33.8 percent). In the study group, 21.1 percent had some adverse reaction, being chills the most frequent. The highest number of cases went to Wagner classification II (31.1 percent) and III (32.4 percent); the lesions healed in 84.1 percent of patients whereas 2.6 percent were amputated. Conclusions: It was observed that type 2 diabetic men aged over 60 years were more likely to suffering the disease, to having few adverse reactions, to healing more frequently and to being less amputated(AU)

Characteristics and Outcomes of Concurrently Diagnosed New Rapid Atrial Fibrillation or Flutter and New Reduced Ejection Fraction.

BACKGROUND: Characteristics and outcomes of concurrently diagnosed new rapid atrial fibrillation (AF) or atrial flutter (AFL) and new heart failure with reduced left ventricular ejection fraction (LVEF) are not well described. METHODS: A retrospective cohort study of subjects referred for expedited transesophageal echocardiography-guided rhythm-control strategies for concurrent new rapid AF/AFL and new LVEF ≤ 40% diagnosed during the same admission was analyzed. RESULTS: Twenty-five subjects (median age 57 years; 96% male; 96% Caucasian; median CHA2 DS2 -VASc = 2) presented with new AF (n = 18) or AFL (n = 7) with rapid ventricular rate (median 135 beats/min) and new reduced LVEF (median 27%; range, 10-37.5%). Seven (28%) subjects had left atrial appendage thrombi (LAAT) and five (20%) subjects had heavy or binge alcohol use. Baseline characteristics were similar between those with and without LAAT. Thirteen subjects with AF and without LAAT underwent direct-current cardioversion (DCCV) and 10 (77%) had AF recurrence within 90 days. Improvement of long-term LVEF to >40% was comparable for subjects with and without initial LAAT (83% vs 94%; P = 0.46). Three of four subjects who received primary prophylaxis implantable cardioverter-defibrillators improved their LVEF to >35% after sinus rhythm maintenance. The median long-term follow-up time was 3.0 years. CONCLUSIONS: Subjects with concurrently diagnosed new rapid AF/AFL and new reduced LVEF are characterized by a high prevalence of LAAT and significant alcohol use. AF subjects without initial LAAT who underwent DCCV had a high 90-day AF recurrence rate. The presence of LAAT did not have a prognosticative effect on eventual LVEF improvement, which was observed in almost all subjects.

Emergent transcutaneous embolization in an advanced carcinosarcoma.

Active hemorrhage is a life-threatening complication of advanced tumors. It often signifies the terminal stage of the disease and therefore is usually treated with palliative care. Transcutaneous arterial embolization (TAE) is a safe, noninvasive procedure that halts acute tumor-related bleeding thereby providing effective life-saving treatment for patients with non-operable tumors. Carcinosarcoma is an uncommon tumor that generally affects the head and neck, respiratory tract, colon, uterus, ovaries, and fallopian tubes. The authors present an interesting case of a rare manifestation in an unusual location. A 60-year-old Caucasian male, who presented with abdominal and groin pain, was found to have a large carcinosarcoma in the retroperitoneal space. The tumor was complicated with an active bleed. Since he was not a candidate for surgical intervention, a TAE was performed. Two days later, the patient was discharged to hospice where he was able to live out the rest of his life.

Tricuspid insufficiency after laser lead extraction.

BACKGROUND: The use of laser lead extraction (LLE) to remove pacemaker and implantable cardiac defibrillator leads has become more prevalent in the past decade. Though the procedure is associated with a low rate of complications, LLE still poses some risks to patients. Some reports have suggested an increase in tricuspid insufficiency (TI) associated with LLE. We present a series of patients who underwent both LLE and complete evaluation for TI with echocardiographic techniques. METHODS: From August 2008 to January 2010, 173 prospective, consecutive patients underwent LLE in a single center. All patients had transesophageal echocardiograms (TEE) during the extraction. Fifty-three patients had tricuspid valve function evaluated a day before the procedure with a transthoracic echocardiogram (TTE), during the procedure with a TEE and 2 days postoperatively with a TTE. RESULTS: All 173 patients experienced no change in tricuspid valve function during the procedure with TEE. Of the 53 patients who underwent a complete TI evaluation, 38 were males (72%) and 15 females (38%), with a mean age of 69.45 ± 14.08. Mean ejection fraction was 35.82 ± 14.72. Three (6%) patients experienced TI after the procedure (two mild and one severe, all with tricuspid valve endocarditis); 16 (30%) patients were found to have TI before LLE that returned to normal valve function during or after the procedure. Thirty-four (64%) patients did not experience any significant change of the tricuspid valve performance after LLE. CONCLUSION: LLE was not associated with increased TI.

Conservative management of an elderly patient with Eisenmenger syndrome.

BACKGROUND: Eisenmenger syndrome (ES) in the adult population has become exceedingly rare in developed countries owing to better recognition and treatment of congenital malformations of the heart. In the absence of transplantation, most patients survive an average of 20-30 years before succumbing to the cardiovascular and hemostatic sequelae. We present a rare case of an elderly woman with ES secondary to an uncorrected atrial-septum defect. She continues to have a high functional capacity despite impressive hemodynamic parameters. CASE: A 69-year-old woman with ES presented to our facility with atrial fibrillation and volume overload. She has a known sinus venosus atrial septal defect and associated severe pulmonary hypertension. She was managed conservatively and discharged on bosentan given her intricate physiology. CONCLUSION: Given the similarity of the pathology with idiopathic pulmonary arterial hypertension (IPAH) and ES, drugs that are usually reserved for IPAH such as prostanoids and phosphodiesterase type 5 inhibitors may be beneficial in the management of ES. This case highlights that with our improving understanding of ES, non-operative management may have an expanding role in the care of these complex patients..

Management of cardiac device-related infections: a review of protocol-driven care.

BACKGROUND: The prevalence of cardiac device-related infections (CDIs) has mirrored the unprecedented increase in device usage. CDIs are currently one of the leading indications for extraction. Despite this, there is limited data regarding the clinical trends, management and outcomes associated with this complication. METHODS: A review of a prospective registry of all patients undergoing device extraction between January 1, 2004, and June 15, 2009, at a single high-volume tertiary referral center was performed. RESULTS: A total of 506 consecutive patients were identified. From these, 350 patients were identified as having a CDI (205 ICD, 145 PPM). The mean age was 69.9 ± 13.7. Although most patients presented clinically with signs of a pocket infection (PI) (42%), the most common final diagnosis was cardiac device infective endocarditis (CDIE) (57%). The two most common pathogens were methicillin-resistant Staphylococcus aureus (27%) and methicillin-resistant Staphylococcus epidermidis (23%); they accounted for 69% of all deaths. Cultures taken from pocket tissue as opposed to exudates displayed higher concordance with lead-tip cultures (56% and 31% respectively). The mean time from explantation to device reimplantation for PIs, bacteremia and CDIE was 6.7 ± 4.7, 10.25 ± 4.7 and 11.39 ± 16.6 days respectively. CONCLUSION: CDIs are a serious complication associated with device usage. Diagnosis and management protocols for CDIs should feature transesophageal echocardiography; complete hardware extraction; broad-spectrum antibiotics that cover methicillin-resistant Staphylococci and cultures derived from lead-tips and preferably pocket tissue. Immediate device reimplantation is possible in noninfectious cases; several factors should be considered regarding reimplantation in cases involving CDIs.

Cardiac device-related endocarditis complicated by spinal abscess.

BACKGROUND: Infective endocarditis is the most serious manifestation of cardiac device infection and metastatic seeding of distant sites has been reported. However, the association between device-related endocarditis and spinal abscess has not been fully described. METHODS: We reviewed hospital records at three high-volume cardiovascular referral centers from January 2005 to October 2010. Device-related endocarditis was confirmed in all cases with positive blood cultures and transesophageal echocardiogram revealing lead and/or valvular vegetations. Six patients with spinal abscesses in association with device-related endocarditis were identified. RESULTS: A total of 384 patients met the clinical criteria for device-related endocarditis. Among these, infection was complicated by spinal abscess formation in six (1.5%) cases. The mean age of patients was 69.3 ± 11.8 years (47-82 years). The predominant clinical manifestations in these six patients included a recent history of fever (six), malaise (four), and neurological or meningeal signs (five). Spinal abscesses were diagnosed by magnetic resonance imaging in two and computed tomography scans in four of the cases. The causative pathogens were methicillin-resistant Staphylococcus aureus (three), methicillin-sensitive S. aureus (one), coagulase-negative Staphylococci (two), and Enterococcus fecalis (one). All patients underwent complete device removal with no procedure-related complications. Two patients died in the hospital, two were discharged with permanent neurological deficits, and the remaining two recovered with no permanent neurologic sequelae. CONCLUSION: Device-related endocarditis must be considered in patients who present with a spinal abscess and bacteremia. Early recognition of this scenario is imperative in order to avoid permanent neurological sequelae and patient mortality. Early imaging, appropriate parenteral antimicrobial therapy, and expedited removal of all cardiac hardware are pivotal for optimal management.

Traumatic transection of the left anterior descending artery caused by a projectile.

BACKGROUND: Coronary lesions caused by penetrating trauma are rare and associated with high mortality rates. Management depends on factors such as the location of the affected vessel and the degree of myocardial dysfunction. We present a case of penetrating cardiac trauma resulting in the subsequent occlusion of the distal left anterior descending artery (LAD) leading to the development of an apical myocardial infarct. CASE: A 21-year-old male was shot with a BB-pellet in the third, left intercostal space, 2 cm lateral to the sternum. The patient proceeded to experience an apical myocardial infarction after an emergent median sternotomy and underwent a catheterization. The mid-LAD was noted to have a thrombus tamponading the site of injury. We opted for conservative management to avoid the possibility of further expanding the suspected perforation. Also, the myocardial area supplied by this vessel was relatively small. CONCLUSION: Complex cardiac injuries that include injury to the LAD are associated with higher mortality rates. Our patient had total occlusion of the distal LAD, which caused an uncomplicated apical myocardial infarction. He was successfully managed with conservative medical treatment. Our patient was well at a 2-month follow-up visit and demonstrated further improvement in left ventricular function.

Laser lead extraction in the octogenarian patient.

BACKGROUND: In the United States, patients aged >75 years are the most rapidly growing segment in the population, with an expected increase of 126% by 2050. These patients account for >70% of the pacemakers and up to two thirds of the implantable cardioverter-defibrillators implanted annually. Our aim was to explore the clinical outcomes of device complications in the octogenarian population. METHODS AND RESULTS: We performed a retrospective chart review of 506 patients undergoing laser lead extraction from January 2004 to September 2009. This population was divided into the following 2 groups based solely on age: octogenarians and nonoctogenarians. These 2 groups were compared on the basis of several characteristics and clinical outcomes. There were 118 patients in the octogenarian group (78 men) and 388 in the nonoctogenarians group (301 men) aged 85±3.8 and 64.2±12.4 years, respectively. A total of 253 leads (atrial, 99; ventricular, 145; coronary sinus, 9) were removed from the patients in the octogenarian group, and 814 leads (atrial, 295; ventricular, 442; coronary sinus, 77) were removed from the patients in the nonoctogenarian group. The main indication for extraction for both groups was infection. The lead implant duration was 59.6±52.8 and 38.6±43.9 months for octogenarians and nonoctogenarians, respectively. There was no significant difference with respect to the proportion of minor (P=0.65), major (P=0.56), and total (P=0.50) complications. CONCLUSIONS: Laser lead extraction is demonstrated to be a safe and effective treatment method in octogenarian patients with multiple comorbidities.

Management of symptomatic inadvertently placed endocardial leads in the left ventricle.

BACKGROUND: There are limited data regarding the clinical care of inadvertently placed endocardial leads in the left ventricle (LV). We clarified the appropriate management within the context of our experience and published literature. METHODS: Hospital charts dating from October 2008 to December 2010 were reviewed at a high-volume cardiovascular tertiary referral center. Six patients were identified with inadvertently placed leads in the LV through an atrial septal defect. RESULTS: Six patients (four males, two females) underwent LV lead removal, four through open surgical intervention and two percutaneously. Three (50%) patients presented with severe mitral regurgitation; one (16%) with a thromboembolic transient ischemic attack and two (33%) were asymptomatic. The mean age was 68.5 ± 8.48 years (55-78). Mean ejection fraction was 38.47 ± 11.1% (25%-50%). Four patients (66%) had a pacemaker and two (33%) had implantable cardioverter defibrillators. Comorbidities consisted of diabetes mellitus (50%), chronic renal failure (16%), severe chronic pulmonary hypertension (16%), and congestive heart failure (33%). Hypertension and coronary arterial disease were present in all patients. All patients had complete extraction or repositioning without intraoperative complications or mortality within 30 days. At 6-month follow-up, the patient with severe pulmonary hypertension died of pneumonia and the other five were alive and well. CONCLUSION: The avoidance and early recognition of inadvertently placed endocardial leads in the LV is imperative in order to avoid potentially serious sequelae and invasive interventions. Treatment usually consists of surgical extraction, although anticoagulation and percutaneous simple traction techniques are an option in certain scenarios.