[Validation of a high sensitive troponin 99th percentile obtained in a general hospital]. / Validación de percentil 99 de troponina ultrasensible obtenido en la población de un hospital general.

Introduction: High sensitivity cardiac Troponin T (hs-cTnT) dosage is recommended for myocardial infarction diagnosis, by applying the 99th percentile obtained from a healthy population by the manufacturer. The objective is to validate the 99th percentile in a population from our hospital (99L), compared with the manufacturer´s 99th percentile (99F) by using coronary angiography as gold standard. Materials and Methods: Retrospective analysis of every hs-cTnT (Roche) obtained from patients admitted with acute coronary syndromes (ACS) who underwent coronary angiography between 2015 and 2018. Results: 415 patients were included for analysis (118 females, 64.2 yo). 99F sensitivity (Sn) for significant coronary artery disease (stenosis >70%) was 83.6%, with a specificity (Sp) of 44.5%. Positive predictive value (PPV) and negative predictive value (NPV) were 77% and 55% respectively. 99L Sn was 69.7% and Sp 58.6%. PPV was 79% and NPV 46%. ROC curve was 0.641 for 99F and 0.641 for 99L. Conclusion: Given the importance of hs-cTnT in ACS diagnosis, the 99F should be the preferred upper reference limit since the sensitivity is better, although lower compared to prior studies.

Introducción: El dosaje de troponina ultrasensible (TnT US) se recomienda para el diagnóstico de infarto de miocardio, para lo cual se utiliza como punto de corte el percentil 99 (p99) obtenido por el fabricante (99F) en población sana. El objetivo de este estudio es validar el p99 obtenido en la población de este hospital (99L) frente al 99F, utilizando la cinecoronariografía (CCG) como gold standard. Materiales y Métodos: análisis retrospectivo de TnT US Roche realizada a todos los pacientes que ingresaron por SCA (síndrome coronario agudo) a los que se les realizó CCG entre 2015 y 2018. Se utilizó para el procesamiento estadístico el programa IBM SPSS Statistics 24 y tablas de sensibilidad y especificidad para métodos diagnósticos (EviCardio). Resultados: se incluyeron 415 pacientes, 118 de sexo femenino, con edad de 64,2 ± 12,5 años. La sensibilidad del 99F para diagnóstico de enfermedad coronaria severa (obstrucción ≥ 70%) fue de 83,6% y la especificidad, 44,5%. El valor predictivo positivo (VPP) fue de 77% y el negativo (VPN) 55%. La sensibilidad del 99L se calculó en 69,7% y la especificidad, 58,6%. El VPP fue 79% y el VPN 46%. El ABC (área bajo la curva) resultó ser 0,641 para el 99Fy 0,641 para el 99L Conclusiones: Debido a la importancia de la sensibilidad en el uso de la TnT US como herramienta diagnóstica ante la sospecha de SCA, debemos seguir utilizando el 99F ya que mostró mayor sensibilidad que 99L (aunque menor a la reportada en estudios previos).

Miocardiopatía hipertrófica: ¿cómo evaluamos en 2018 el riesgo de muerte súbita? / Hypertrophic cardiomyopathy: how do we evaluate the risk of sudden death in 2018?

Resumen: La miocardiopatía hipertrófica (MCH) es una enfermedad frecuente del miocardio, asociada a muerte súbita cardíaca (MSC). Las principales causas de muerte en MCH son la MSC, la insuficiencia cardíaca y el tromboembolismo. La fibrilación ventricular (FV) es la causa más común de MSC, seguida de asistolia, actividad eléctrica sin pulso y bloqueo auriculoventricular completo. El sustrato de estas arritmias complejas es la hipertrofia asociada a desorganización miofibrilar y fibrosis, que facilitan el desarrollo de arritmias reentrantes y secundarias a actividad desencadenada. Dado que la FV puede ser tratada con el implante de un desfibrilador automático implantable (DAI), la identificación de los pacientes que presentan mayor riesgo se transforma en la principal preocupación del cardiólogo tratante. La indicación de implante de DAI es clara en la prevención secundaria de MSC, pero es compleja en el resto de los pacientes que no han presentado FV o taquicardia ventricular sostenida, lo que configura la prevención primaria de MSC. Debemos estratificar la MCH con el uso de los factores de riesgo derivados de datos clínicos y estudios complementarios. Los principales factores de riesgo relacionados a MSC son: edad temprana al diagnóstico, antecedentes heredofamiliares de MSC, síncope inexplicado, taquicardia ventricular no sostenida, hipotensión arterial inducida durante la prueba de esfuerzo, obstrucción del tracto de salida del ventrículo izquierdo, hipertrofia ventricular izquierda severa, agrandamiento auricular izquierdo y captación de realce tardío en la resonancia magnética. El uso adecuado de los dos principales modelos de estratificación de riesgo actualmente disponibles nos ayuda a estimar el riesgo individual en cada paciente y proceder en consecuencia.

Summary: Hypertrophic cardiomyopathy is one of the most frequent cardiac muscle disorders associated with sudden cardiac death, heart failure and thromboembolism. Ventricular fibrillation is the most common cause of sudden cardiac death in hypertrophic cardiomyopathy, followed by asystole, pulseless electrical activity, and complete atrioventricular block. The substrate behind these complex arrhythmias is the hypertrophy due to myocardial disarray and fibrosis, facilitating the development of reentrant arrhythmias and triggered activity. An implanted cardioverter defibrillator is the treatment of choice, so the identification of high risk patients for ventricular fibrillation is crucial. Implanted cardioverter defibrillator indication is well established in sudden cardiac death secondary prevention, but not in patients without evidence of ventricular fibrillation or sustained ventricular tachycardia, which configures the sudden cardiac death primary prevention group. Identification of sudden cardiac death risk factors is derived from clinical data, complementary studies and validated in risk stratification models. These are: early age at diagnosis, family history of sudden death, unexplained syncope, non-sustained ventricular tachycardia, abnormal blood pressure response with exercise, left ventricular outflow tract obstruction, severe left ventricular hypertrophy, left atrial enlargement and late gadolinium enhancement on cardiac magnetic resonance imaging. The proper use of two available main risk stratification models helps us to estimate the individual patient´s risk and to proceed consequently.

Desproporción prótesis-paciente luego de reemplazo de válvula aórtica y seguimiento a 6 años / Patient-prosthesis mismatch in aortic valve replacement: a 6 year follow up

Resumen: Introducción: La desproporción prótesis-paciente (DPP) tras cirugía valvular ocurre cuando el área efectiva de orificio protésico (AEO) es fisiológicamente demasiado pequeño en relación con el tamaño del paciente, lo que resulta en gradientes postoperatorios elevados. Material y métodos: Se realizó un estudio observacional retrospectivo. Se analizaron pacientes con estenosis aórtica sometidos a reemplazo de válvula aórtica durante el año 2010. Se calculó AEO/ASC postoperatorio, si AEO/ASC fue menor de 0,85 cm2/ m2 el paciente fue clasificado como desproporción prótesis-paciente. Los eventos clínicos analizados fueron: mortalidad por cualquier causa, recambio valvular, internación por insuficiencia cardiaca y la capacidad funcional al momento de la encuesta. Se realizaron estadísticas descriptivas para analizar las características de la población. Las variables categóricas se expresaron en porcentaje y las variables continuas en promedio y desviación estándar. El análisis estadístico se realizó con el software IBM® SPSS® 19. Resultados: Se analizaron 26 pacientes sometidos a reemplazo de válvula aórtica con un seguimiento a 6 años, 13 de ellos presentaron DPP y mayor porcentaje de disnea, internación por insuficiencia cardiaca y muerte por cualquier causa. La combinación de eventos clínicos en este grupo de pacientes fue del 53,9%. Conclusión: Se observó un mayor número de eventos cardiovasculares en aquellos pacientes que con des- proporción prótesis-paciente.

Abstract: Background: Prosthesis-patient mismatch (PPM) after aortic valve replacement is related to inferior long-term outcomes. The study aim was to describe the rate of cardiovascular events in patients with or without PPM. Methods: The study was based on a retrospective analysis of information obtained from the electronic medical record. All patients undergoing aortic valve replacement, with or without revascularization surgery during 2010 were included. The effective orifice area (EOA) of the prothesis was obtained based on prosthetic valve data from echocardiography recommendations, was related to body surface area (BSA). PPM was diagnosed when EOA / BSA was < 0.85 cm2/m2. Clinical results were evaluated in January 2017 through our electronic medical record data base and a telephone interview. Helsinki criteria for clinical research were respected. Results: 26 patients were analyzed (20 males) with mean age 64 (SD 11.5) years old. A mechanical prosthesis was implanted in 10 patients and a biological one in the remaining subjects. 13 patients had DPP (EOA/BSA 0.77 ± 0.06). At a mean follow up period of 2190 days 44% were in functional class (NYHA) II-III, 31% had been re-hospitalized for heart failure and 8% had died from cardiac causes (overall death rate 31%). The combined outcome rate (overall death, hospitalization for heart failure or re-replacement of the valve) was 54%. Among the 13 patients without PPM, 31% were in functional class II-III, there were no hospitalizations for heart failure and only 4 patients had died from cardiac causes. Combined outcome rate was 23%. Conclusions: PPM was a marker of poorer clinical results on a long term follow up of patients undergoing aortic valve replacement. Inferential statistical analysis was not performed due to the relatively low number of patients included.

The effect of rivaroxaban on myocardial infarction in the ATLAS ACS 2 - TIMI 51 trial.

AIMS: Rivaroxaban reduces cardiovascular death, myocardial infarction (MI), or stroke in patients following acute coronary syndrome (ACS). We aimed to characterize the specific effects of rivaroxaban on the size and type of MI. METHODS: The Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with Acute Coronary Syndrome-Thrombolysis in Myocardial Infarction 51 (ATLAS ACS 2-TIMI 51) study randomized 15,526 patients with a recent ACS to rivaroxaban 2.5 mg BID, rivaroxaban 5 mg BID, or placebo. An independent clinical events committee adjudicated each MI that occurred during the study and further classified them based on type. Data are presented as two-year Kaplan-Meier event rates and hazard ratios (HRs) and 95% confidence intervals (CI). RESULTS: In total, 665 patients experienced a post-randomization MI. The majority (n=535, 80.5%) were spontaneous (Type 1) events. Rivaroxaban reduced spontaneous MI when compared with placebo (4.4% vs 5.7%, HR 0.80, 95% 0.67-0.95, p=0.01), and there were directionally consistent reductions with both the 2.5 mg BID (4.7% vs 5.7%, HR 0.84, 95% 0.68-1.02, p=0.08) and 5 mg BID doses (4.1% vs 5.7%, HR 0.77, 95% 0.62-0.94, p=0.01) as compared with placebo. Rivaroxaban reduced MI with large elevations in troponin or creatine kinase-MB (CK-MB) fraction (1.8% vs 2.4%, HR 0.73, 95% CI 0.56-0.96, p=0.03) and STEMI events (1.7% vs 2.5%, HR 0.74, 95% CI 0.56-0.99, p=0.04). CONCLUSIONS: In patients stabilized and followed after ACS, the majority of MIs that occur are spontaneous and rivaroxaban significantly reduced the incidence of these events. Notably, rivaroxaban reduced MIs with extensive biomarker release and ST-segment elevation.

Disulfiram--alcohol reaction mimicking an acute coronary syndrome.

Disulfiram treatment for alcohol dependence is used with acceptable outcomes. By inhibiting the aldehyde dehydrogenase enzyme, this treatment increases acetaldehyde concentration after the ingestion of alcohol causing an unpleasant disulfiram-alcohol reaction. Typical symptoms include flushing, headache, nausea, vomiting, sweating, vertigo, and lightheadedness. However, there have also been descriptions of more serious reactions including severe hypotension, arrhythmias, myocardial infarction, and cardiovascular collapse. We report a patient with a severe disulfiram-alcohol reaction marked by flushing, confusion, generalized malaise, epigastric pain, and hypotension. Cardiac biomarker and electrocardiographic changes were suggestive of non-ST-elevation myocardial infarction (NSTEMI). Left heart catheterization showed no angiographic evidence of coronary artery disease. Because of the frequency of alcohol dependence and its treatment with disulfiram, it is critical for physicians to be aware of these types of life-threatening complications.

Correlación de los parámetros ecocardiográficos de estenosis aórtica en pacientes con fracción de eyección normal / Correlation of aortic stenosis echocardiographic parameters in patients with normal ejection fraction / Correlação dos parâmetros ecocardiográficos de estenose aórtica em pacientes com fração de ejeção normal

Introducción. El ecocardiograma es el método de elección para evaluar la severidad de la estenosis aórtica (EA), pero a menudo existen discrepancias entre los parámetros ecocardiográficos. El objetivo de nuestro trabajo fue evaluar la correlación entre los parámetros ecocardiográficos utilizados para graduar la severidad de la estenosis aórtica: área valvular aórtica (AVA), gradiente transvalvular medio (GM) y velocidad sistólica máxima (VM), y valorar la discordancia entre el AVA y el GM para el diagnóstico de EA severa. Material y métodos. Se incluyeron de forma consecutiva pacientes a los que se les realizó un ecocardiograma transtorácico como parte del seguimiento de su estenosis aórtica. Se calculó el AVA por ecuación de continuidad, el AVA indexado (AVAi), la VM y el GM con Doppler continuo. Mediante el método de correlación bivariada se obtuvo el coeficiente de correlación de Pearson entre las variables AVA y AVAi-GM, AVA y AVAi-VM. Se consideró una p<0,05, estadísticamente significativa. Además, se dividió a la población en 4 grupos de acuerdo a los siguientes parámetros ecocardiográficos, AVA ≥1 cm² y <1cm²; AVAi ≥0,6 cm²/m² y <0,6 cm²/m² y GM ≥40 mm Hg y <40 mm Hg. Las variables categóricas se expresan en porcentaje y las variables continuas en promedio y desviación estándar. Resultados. Fueron incluidos 104 pacientes con un AVA promedio de 1,24 ± 0,40 cm², AVAi promedio de 0,67 ± 0,22 cm²/m², una VM promedio de 3,34 ± 0,89 m/seg y un GM promedio de 27,9 ± 17,6 mm Hg. Hubo correlación significativa entre las variables: AVA-GM (coeficiente de correlación 0,738; p<0,01), AVA-VM (coeficiente de correlación de 0,801; p<0,01). Se mantuvo la misma correlación cuando se comparó GM y VM con AVAi. Al dividir por grupos de acuerdo al área valvular y GM, hubo discordancia de los parámetros ecocardiográficos de estenosis aórtica severa en 12,5% y 17,3%, con AVA o AVAi, respectivamente. Conclusión. Existe correlación estadística entre los parámetros ecocardiográficos para evaluar la EA, pero hay discordancia de 12,5 ó 17,3% entre el AVA o AVAi, respectivamente, y GM para valorar EA severa.

Backround. Echocardiography is the method of choice for evaluating the severity of aortic stenosis, but there are often discrepancies between echocardiographic parameters. The aim of our study was to evaluate the correlation between echocardiographic parameters used to grade the severity of aortic stenosis: aortic valve area (AVA), mean transvalvular gradient (MG) and peak systolic velocity (PV) and assess the discordance between AVA and mean gradient for the diagnosis of severe aortic stenosis. Material and methods. We included consecutively patients who underwent transthoracic echocardiography as part of follow up of aortic stenosis. Was calculated AVA by continuity equation, indexed AVA (iAVA), PV and MG with continuous Doppler. By the method of bivariate correlation was obtained Pearson correlation coefficient between AVA and iAVA-MG, AVA and iAVA-PV. We considered a p<0.05 statistically significant. In addition, the population was divided into 4 groups according to the following echocardiographic parameters, AVA ≥1 cm² and <1 cm²; iAVA ≥0.6 cm²/m² and <0.6 cm²/m² and GM ≥40 mm Hg and <40 mm Hg. Results. We included104 patients with a mean AVA of 1.24 ± 0.40 cm², a mean iAVA of 0.67 ± 0.22 cm²/m², a mean PV of 3.34 ± 0.89 m/sec and a mean MG of 27.9 ± 17.6 mm Hg. There was significant correlation between the variables: AVA-MG (correlation coefficient 0.738, p<0.01), AVA-PV (correlation coefficient of 0.801, p<0.01). Remained the same correlation when compared iAVA with MG and PV. Dividing into groups according to valve area and MG, there was discrepancy of echocardiographic parameters of severe aortic stenosis in 12.5% and 17.3%, with AVA or iAVA respectively. Conclusion. Statistical correlation exists between echocardiographic parameters to assess aortic stenosis, but there is disagreement of 12.5 or 17.3%, between AVA or iAVA and mean gradient respectively to assess severe aortic stenosis.

Introdução. O ecocardiograma é o método de escolha para avaliar a gravidade da estenose aórtica, mas muitas vezes há divergências entre os parâmetros ecocardiográficos. O objetivo do nosso estudo foi avaliar a correlação entre os parâmetros ecocardiográficos utilizados para classificar a gravidade da estenose aórtica: área da válvula aórtica (AVA), gradiente transvalvular médio (GM) e velocidade sistólica máxima (VM), e avaliar a discordância entre AVA e GM para o diagnóstico de estenose aórtica grave. Material e métodos. Foram incluídos consecutivamente pacientes que se submeteram a ecocardiografia transtorácica como parte do monitoramento de sua estenose aórtica. A AVA foi calculada pela equação da continuidade, a AVA indexada (AVAi), a VM e GM com Doppler continuo. Pelo método de correlação bivariada foi obtido coeficiente de correlação de Pearson entre as variáveis AVA e AVAi-GM, AVA e AVAi-VM. Foi considerado uma p<0,05 estatisticamente significativa. Além disso, a população foi dividida em quatro grupos de acordo com os seguintes parâmetros ecocardiográficos, AVA ≥ 1 cm2 e <1 cm²; AVAi ≥0,6 cm²/m² e <0,6 cm²/m² e GM ≥40 mm Hg e < 40 mm Hg. As variáveis categóricas foram expressas em porcentagens e as variáveis contínuas em média e desvio padrão. Resultados. Foram incluídos 104 pacientes com uma AVA média de 1,24 ± 0,40 cm², AVAi média de 0,67 ± 0,22 cm²/m², uma VM média de 3,34 ± 0,89 m/seg e um GM média de 27,9 ± 17,6 mm Hg. Houve correlação significativa entre as variáveis: AVA-GM (coeficiente de correlação 0,738, p<0,01), AVA-VM (coeficiente de correlação de 0,801, p<0,01). Mesma correlação foi mantida quando comparado GM e VM com AVAi. Dividindo-se em grupos de acordo com a área da válvula e GM, houve discordância de parâmetros ecocardiográficos de estenose aórtica grave em 12,5% e 17,3%, com AVA ou AVAi, respectivamente. Conclusão. Existe correlação estatística entre os parâmetros ecocardiográficos para avaliar ...

Correlación de los parámetros ecocardiográficos de estenosis aórtica en pacientes con fracción de eyección normal / Correlation of aortic stenosis echocardiographic parameters in patients with normal ejection fraction / CorrelaþÒo dos parÔmetros ecocardiográficos de estenose aórtica em pacientes com fraþÒo de ejeþÒo normal

Introducción. El ecocardiograma es el método de elección para evaluar la severidad de la estenosis aórtica (EA), pero a menudo existen discrepancias entre los parámetros ecocardiográficos. El objetivo de nuestro trabajo fue evaluar la correlación entre los parámetros ecocardiográficos utilizados para graduar la severidad de la estenosis aórtica: área valvular aórtica (AVA), gradiente transvalvular medio (GM) y velocidad sistólica máxima (VM), y valorar la discordancia entre el AVA y el GM para el diagnóstico de EA severa. Material y métodos. Se incluyeron de forma consecutiva pacientes a los que se les realizó un ecocardiograma transtorácico como parte del seguimiento de su estenosis aórtica. Se calculó el AVA por ecuación de continuidad, el AVA indexado (AVAi), la VM y el GM con Doppler continuo. Mediante el método de correlación bivariada se obtuvo el coeficiente de correlación de Pearson entre las variables AVA y AVAi-GM, AVA y AVAi-VM. Se consideró una p<0,05, estadísticamente significativa. Además, se dividió a la población en 4 grupos de acuerdo a los siguientes parámetros ecocardiográficos, AVA ≥1 cm² y <1cm²; AVAi ≥0,6 cm²/m² y <0,6 cm²/m² y GM ≥40 mm Hg y <40 mm Hg. Las variables categóricas se expresan en porcentaje y las variables continuas en promedio y desviación estándar. Resultados. Fueron incluidos 104 pacientes con un AVA promedio de 1,24 ± 0,40 cm², AVAi promedio de 0,67 ± 0,22 cm²/m², una VM promedio de 3,34 ± 0,89 m/seg y un GM promedio de 27,9 ± 17,6 mm Hg. Hubo correlación significativa entre las variables: AVA-GM (coeficiente de correlación 0,738; p<0,01), AVA-VM (coeficiente de correlación de 0,801; p<0,01). Se mantuvo la misma correlación cuando se comparó GM y VM con AVAi. Al dividir por grupos de acuerdo al área valvular y GM, hubo discordancia de los parámetros ecocardiográficos de estenosis aórtica severa en 12,5% y 17,3%, con AVA o AVAi, respectivamente. Conclusión. Existe correlación estadística entre los parámetros ecocardiográficos para evaluar la EA, pero hay discordancia de 12,5 ó 17,3% entre el AVA o AVAi, respectivamente, y GM para valorar EA severa.(AU)

Backround. Echocardiography is the method of choice for evaluating the severity of aortic stenosis, but there are often discrepancies between echocardiographic parameters. The aim of our study was to evaluate the correlation between echocardiographic parameters used to grade the severity of aortic stenosis: aortic valve area (AVA), mean transvalvular gradient (MG) and peak systolic velocity (PV) and assess the discordance between AVA and mean gradient for the diagnosis of severe aortic stenosis. Material and methods. We included consecutively patients who underwent transthoracic echocardiography as part of follow up of aortic stenosis. Was calculated AVA by continuity equation, indexed AVA (iAVA), PV and MG with continuous Doppler. By the method of bivariate correlation was obtained Pearson correlation coefficient between AVA and iAVA-MG, AVA and iAVA-PV. We considered a p<0.05 statistically significant. In addition, the population was divided into 4 groups according to the following echocardiographic parameters, AVA ≥1 cm² and <1 cm²; iAVA ≥0.6 cm²/m² and <0.6 cm²/m² and GM ≥40 mm Hg and <40 mm Hg. Results. We included104 patients with a mean AVA of 1.24 ± 0.40 cm², a mean iAVA of 0.67 ± 0.22 cm²/m², a mean PV of 3.34 ± 0.89 m/sec and a mean MG of 27.9 ± 17.6 mm Hg. There was significant correlation between the variables: AVA-MG (correlation coefficient 0.738, p<0.01), AVA-PV (correlation coefficient of 0.801, p<0.01). Remained the same correlation when compared iAVA with MG and PV. Dividing into groups according to valve area and MG, there was discrepancy of echocardiographic parameters of severe aortic stenosis in 12.5% and 17.3%, with AVA or iAVA respectively. Conclusion. Statistical correlation exists between echocardiographic parameters to assess aortic stenosis, but there is disagreement of 12.5 or 17.3%, between AVA or iAVA and mean gradient respectively to assess severe aortic stenosis.(AU)

IntroduþÒo. O ecocardiograma é o método de escolha para avaliar a gravidade da estenose aórtica, mas muitas vezes há divergÛncias entre os parÔmetros ecocardiográficos. O objetivo do nosso estudo foi avaliar a correlaþÒo entre os parÔmetros ecocardiográficos utilizados para classificar a gravidade da estenose aórtica: área da válvula aórtica (AVA), gradiente transvalvular médio (GM) e velocidade sistólica máxima (VM), e avaliar a discordÔncia entre AVA e GM para o diagnóstico de estenose aórtica grave. Material e métodos. Foram incluídos consecutivamente pacientes que se submeteram a ecocardiografia transtorácica como parte do monitoramento de sua estenose aórtica. A AVA foi calculada pela equaþÒo da continuidade, a AVA indexada (AVAi), a VM e GM com Doppler continuo. Pelo método de correlaþÒo bivariada foi obtido coeficiente de correlaþÒo de Pearson entre as variáveis AVA e AVAi-GM, AVA e AVAi-VM. Foi considerado uma p<0,05 estatisticamente significativa. Além disso, a populaþÒo foi dividida em quatro grupos de acordo com os seguintes parÔmetros ecocardiográficos, AVA ≥ 1 cm2 e <1 cm²; AVAi ≥0,6 cm²/m² e <0,6 cm²/m² e GM ≥40 mm Hg e < 40 mm Hg. As variáveis categóricas foram expressas em porcentagens e as variáveis contínuas em média e desvio padrÒo. Resultados. Foram incluídos 104 pacientes com uma AVA média de 1,24 ± 0,40 cm², AVAi média de 0,67 ± 0,22 cm²/m², uma VM média de 3,34 ± 0,89 m/seg e um GM média de 27,9 ± 17,6 mm Hg. Houve correlaþÒo significativa entre as variáveis: AVA-GM (coeficiente de correlaþÒo 0,738, p<0,01), AVA-VM (coeficiente de correlaþÒo de 0,801, p<0,01). Mesma correlaþÒo foi mantida quando comparado GM e VM com AVAi. Dividindo-se em grupos de acordo com a área da válvula e GM, houve discordÔncia de parÔmetros ecocardiográficos de estenose aórtica grave em 12,5% e 17,3%, com AVA ou AVAi, respectivamente. ConclusÒo. Existe correlaþÒo estatística entre os parÔmetros ecocardiográficos para avaliar ...(AU)

Isolated left ventricular noncompaction: a review of three different presentations for a rare disease.

Isolated left ventricular noncompaction (ILVNC) is a rare cardiomyopathy with a genetic background characterized by numerous prominent trabeculations and deep intertrabecular recesses. It occurs in the absence of any coexisting congenital lesion or hemodynamic abnormality and is rare in the adult population. Heart failure, ventricular arrhythmias, and embolic events are the three major clinical manifestations of ILVNC. Medical and surgical treatment is similar to other systolic dysfunction cardiomyopathies and depends on the presenting clinical manifestations. In this review, we present three patients with different clinical presentations of ILVNC leading to different treatment modalities ranging from medications alone to device implantation and transplantation. Pathologic findings from one of our patients are also presented.

[Risk of hemorrhage in patients older than 85 years, anticoagulated due to atrial fibrillation]. / Riesgo de hemorragía en pacientes mayores de 85 años anticuagulados por fibrilación auricular.

BACKGROUND: Atrial fibrillation is the most common cardiac tachyarrhythmia and is an important independent risk factor for ischemic stroke. Its prevalence begins to increase in both sexes after 40 years of age as well as the risk of hemorrhage. The aim of this study was to compare the annual rate of hemorrhagic events between patients older and younger than 85 years, with diagnosis of nonvalvular atrial fibrillation and anticoagulated with warfarin. MATERIAL AND METHODS: A retrospective study was performed. We included 118 patients with diagnosis of nonvalvular atrial fibrillation monitorized by an informatized follow up system. RESULTS: The study follow-up was 28,2 ± 17,5 months and 24 patients (20,3%) were older than 85 years of age. The rate of major bleedings was 4,62%/year (older than 85 years) vs 0,95%/year (younger than 85 years) , p= 0,05, OR 6,57 (IC 95% 1,04-41,8) and minor bleeding was 4,62%/year (older than 85 years) vs 5,2%/year (younger than 85 years), p=0,99, OR 1,08 (IC 95% 0,28-4,21). There was no difference in the Time in Therapeutic Range between both groups (56.4 ± 16.3 % vs 60.5 ± 17.7 %, p 0,30). CONCLUSION: The age should not be considered a contraindication to anticoagulant therapy, however, special care and careful monitoring of patients older than 85 years should be considered due to they had high risk of bleeding.

Treatment and outcomes of nonagenarians with ST-elevation myocardial infarction.

There is no age limit for reperfusion therapy in the current guidelines for the treatment of patients with ST-elevation myocardial infarction (STEMI). Reperfusion therapy, although associated with better outcomes, is not always offered to the oldest patients. A retrospective analysis at our institution of all patients ≥ 90 years of age with a diagnosis of acute coronary syndrome at discharge from 2004 to 2008 identified 24 patients with STEMI. The majority of patients were Caucasian, females, hypertensive, with a low incidence of dementia and diabetes. Only 29% of patients presented to the hospital in less than 6 hours. Thirteen patients were treated with percutaneous coronary intervention (PCI) and 11 patients were treated medically. The in-hospital mortality was 23% in the PCI group and 36% in the medical therapy group. Kaplan-Meier analysis demonstrated a survival benefit favoring PCI, which disappeared when only patients presenting after 6 hours to the hospital were analyzed. PCI-treated patients had no procedure-associated complications and had a good prognosis if they survived to hospital discharge. PCI should be offered to nonagenarians presenting with STEMI.

[Ischemic hepatitis]. / Hepatitis isquémica.

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term "hepatitis" was proposed because of a raise in hepatic enzymes similar with infectious disease, and "ischemic" because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presented complaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracic echocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative.

Recomendaciones para el uso de everolimus en pacientes con trasplante cardíaco Resultados de las Jornadas Latinoamericanas de Consenso / Recommendations for the use of everolimus in patients with heart transplantation. Results of the Latin American Consensus Conference

Resumen: Aún cuando los resultados obtenidos en el área de trasplante cardíaco han evolucionado favorablemente durante los últimos años, existen necesidades médicas pendientes cuya resolución beneficiará a los pacientes en el futuro. Algunos de los problemas por resolver son: la vasculopatía del injerto, la insuficiencia renal crónica, la infección por citomegalovirus (CMV) y el rechazo agudo con compromiso hemodinámico. El everolimus es una nueva opción en la terapia inmunosupresora adyuvante; se trata de un fármaco inhibidor del mTOR, que básicamente ofrece un perfil farmacocinético diferente del de su predecesor: el sirolimus. Asimismo, el everolimus es el único fármaco adyuvante con el que se ha comprobado una mayor eficacia en la profilaxis del rechazo agudo, al menos en episodios de grado 3 A de la ISHLT (International Society of Heart and Lung Transplantation) (p<0,001), en la prevención de la vasculopatía del injerto (p<0,01) y en la incidencia de infección por CMV (p<0,01). Dado que la vasculopatía del injerto es el principal factor de riesgo de mortalidad después del primer año del trasplante y que el rechazo agudo y la infección por CMV desempeñan un papel fundamental en su desarrollo, estos hallazgos sugieren que el everolimus desempeñaría un papel importante como parte de la terapia primaria de inmunosupresión en los receptores de trasplante cardíaco. En junio de 2005, se celebraron en Bariloche (Argentina) las Jornadas Latinoamericanas de Consenso sobre el uso de everolimus en el trasplante cardíaco. Allí se reunieron destacados profesionales de la región para evaluar los datos disponibles y establecer, sobre la base de éstos y de su propia experiencia, lineamientos para el uso del everolimus en la práctica diaria.

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de “hepatitis” fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e “isquémica” por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term “hepatitis” was proposed because of a raise in hepaticenzymes similar with infectious disease, and “ischemic” because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de ¶hepatitis÷ fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e ¶isquémica÷ por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos (AU)

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term ¶hepatitis÷ was proposed because of a raise in hepaticenzymes similar with infectious disease, and ¶ischemic÷ because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative (AU)

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de ¶hepatitis÷ fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e ¶isquémica÷ por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos (AU)

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term ¶hepatitis÷ was proposed because of a raise in hepaticenzymes similar with infectious disease, and ¶ischemic÷ because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative (AU)

Using polymerase chain reaction in early diagnosis of re-activated Trypanosoma cruzi infection after heart transplantation.

BACKGROUND: Heart transplantation is an effective treatment for patients with end-stage Chagas' heart disease. Re-activation of Chagas' disease in transplant recipients is frequent, triggered by immunosuppression level. Therefore, highly sensitive methods for early diagnosis of Chagas' disease relapse are necessary to initiate appropriate therapy. We analyzed the use of polymerase chain reaction (PCR) in the clinical follow-up of heart transplant recipients. METHODS: We prospectively evaluated 4 heart transplant recipients at the Hospital Privado, Cordoba, Argentina, who had terminal Chagas' disease. The parameters analyzed were presence of parasites in the blood (blood culture, Strout) and in endomyocardial biopsy (EMB) samples, and PCR was performed with oligonucleotides directed to a nuclear repetitive sequence of Trypanosoma cruzi. We evaluated these parameters weekly from the day of transplantation until results were negative and then during regular follow-up visits. RESULTS: In 2 patients, we detected T cruzi using PCR in peripheral blood 30 days before clinical evidence of re-activation. In the 3rd case, PCR results in peripheral blood were positive from the day before transplantation, followed by positive results in EMB and sub-cutaneous chagomas biopsy specimens. Only 1 patient had positive Strout results for parasites in skin lesions, and none showed amastigotes in the biopsy specimens. After clinical diagnosis, all patients received 5 mg/kg/day benzimidazole for 6 months, with acceptable tolerance and good clinical outcome. All patients had negative peripheral blood PRC results after 30 days of treatment. One patient had intermittent positive PCR results during follow-up, with no evidence of clinical re-activation. CONCLUSION: Polymerase chain reaction detection of T Cruzi in heart transplant recipients is a more sensitive and specific procedure in diagnosing Chagas' disease re-activation.