Ecografía en el postoperatorio de cirugía cardíaca / Ultrasound use after cardiac surgery

La complejidad de los procedimientos quirúrgicos, así como la comorbilidad de los pacientes sometidos a cirugía cardiaca, van en aumento. La detección y el tratamiento precoz de las complicaciones posquirúrgicas son parte del éxito en la reducción de la morbimortalidad. La introducción de la técnica ecográfica ha sido fundamental en la valoración cardiopulmonar, hemodinámica y etiológica del paciente crítico, aportando información inmediata, fiable y a veces concluyente, permitiendo aclarar muchas situaciones clínicas sin respuesta terapéutica aceptable, por lo que se trata de una herramienta diagnóstica esencial. En este capítulo nos centraremos, fundamentalmente, en la valoración funcional y hemodinámica, y en la detección de las complicaciones cardiológicas más frecuentes en el postoperatorio de cirugía cardiaca. (AU)

Surgical complexity as well as comorbidities in patients undergoing cardiac surgery is increasing. Early detection and management of post-surgical complications are key points to reduce morbidity and mortality. Ultrasound technique plays a main rol in cardiopulmonary, hemodynamic and etiological assessment of the critically ill, providing immediate, reliable and, sometimes, conclusive information, clarifying many clinical situations with an inappropriate therapeutic response. For all these reasons ultrasound is an essential diagnostic tool. In this chapter we will focus, mainly, on functional and hemodynamic assessment and on the detection of most common cardiological complications in the postoperative period after cardiac surgery. (AU)

Benefit of primary percutaneous coronary interventions in the elderly with ST segment elevation myocardial infarction.

OBJECTIVE: Primary percutaneous coronary intervention (P-PCI) has demonstrated its efficacy in patients with ST segment elevation myocardial infarction (STEMI). However, patients with STEMI ≥75 years receive less P-PCI than younger patients despite their higher in-hospital morbimortality. The objective of this analysis was to determine the effectiveness of P-PCI in patients with STEMI ≥75 years. METHODS: We included 979 patients with STEMI ≥75 years, from the ATención HOspitalaria del Síndrome coronario study, a registry of 8142 consecutive patients with acute coronary syndrome admitted at 31 Spanish hospitals in 2014-2016. We calculated a propensity score (PS) for the indication of P-PCI. Patients that received or not P-PCI were matched by PS. Using logistic regression, we compared the effectiveness of performing P-PCI versus non-performance for the composite primary event, which included death, reinfarction, acute pulmonary oedema or cardiogenic shock during hospitalisation. RESULTS: Of the included patients, 81.5 % received P-PCI. The matching provided two groups of 169 patients with and without P-PCI. Compared with its non-performance, P-PCI presented a composite event OR adjusted by PS of 0.55 (95% CI 0.34 to 0.89). CONCLUSIONS: Receiving a P-PCI was significantly associated with a reduced risk of major intrahospital complications in patients with STEMI aged 75 years or older.

Long-term prognosis of patients with life-threatening ventricular arrhythmias induced by coronary artery spasm.

Aims: Coronary artery spasm (CAS) is associated with ventricular arrhythmias (VA). Much controversy remains regarding the best therapeutic interventions for this specific patient subset. We aimed to evaluate the clinical outcomes of patients with a history of life-threatening VA due to CAS with various medical interventions, as well as the need for ICD placement in the setting of optimal medical therapy. Methods and results: A multicentre European retrospective survey of patients with VA in the setting of CAS was aggregated and relevant clinical and demographic data was analysed. Forty-nine appropriate patients were identified: 43 (87.8%) presented with VF and 6 (12.2%) with rapid VT. ICD implantation was performed in 44 (89.8%). During follow-up [59 (17-117) months], appropriate ICD shocks were documented in 12. In 8/12 (66.6%) no more ICD therapies were recorded after optimizing calcium channel blocker (CCB) therapy. SCD occurred in one patient without ICD. Treatment with beta-blockers was predictive of appropriate device discharge. Conversely, non-dihydropyridine CCB therapy was significantly protective against VAs. Conclusion: Patients with life-threatening VAs secondary to CAS are at particularly high-risk for recurrence, especially when insufficient medical therapy is administered. Non-dihydropyridine CCBs are capable of suppressing episodes, whereas beta-blocker treatment is predictive of VAs. Ultimately, in spite of medical intervention, some patients exhibited arrhythmogenic events in the long-term, suggesting that ICD implantation may still be indicated for all.

Síndrome de Lemierre en paciente adulto con circulación de Fontan / Lemierre Syndrome in an adult patient with Fontan circulation

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Predictive power of the grace score in population with diabetes.

INTRODUCTION: Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to hospital. Diabetes mellitus (DM) is widely recognized as an independent predictor of mortality in these patients, although it is not included in the GRACE risk score. OBJECTIVES: The objective of this study is to validate the GRACE risk score in a contemporary population and particularly in the subgroup of patients with diabetes, and to test the effects of including the DM variable in the model. MATERIAL AND METHODS: Retrospective cohort study in patients included in the ARIAM-SEMICYUC registry, with a diagnosis of ACS and with available in-hospital mortality data. We tested the predictive power of the GRACE score, calculating the area under the ROC curve. We assessed the calibration of the score and the predictive ability based on type of ACS and the presence of DM. Finally, we evaluated the effect of including the DM variable in the model by calculating the net reclassification improvement. RESULTS: The GRACE score shows good predictive power for hospital mortality in the study population, with a moderate degree of calibration and no significant differences based on ACS type or the presence of DM. Including DM as a variable did not add any predictive value to the GRACE model. CONCLUSIONS: The GRACE score has an appropriate predictive power, with good calibration and clinical applicability in the subgroup of diabetic patients.

Changes in the severity of aortic regurgitation at peak effort during exercise.

BACKGROUND: Chronic aortic regurgitation can be well tolerated for a long time. Some patients with normal ventricular function can even reach high levels of sporting performance. How the severity of regurgitation may change during exercise, however, is little known, although some studies suggest it diminishes. The present work examines, during exercise, the functional capacity, ventricular function, and regurgitation fraction (RF) in asymptomatic subjects with moderate or severe aortic regurgitation with preserved ejection fraction. METHODS: The study subjects (n=32; 23 men, 9 women) were patients referred to our echocardiography laboratory with moderate or severe aortic regurgitation, preserved left ventricular systolic function, and sinus rhythm into NYHA functional class I. All underwent transthoracic echocardiography at rest and at peak effort during an exercise protocol involving an inclined cycloergometer. Left atrial and ventricular volume indices were recorded, along with diastolic and systolic function, cardiac index, peripheral resistance, and RF. RESULTS: The mean age of the subjects was 43.8±18.2years; 59% suffered moderate regurgitation, 41% severe aortic regurgitation, and 84% had a dilated left ventricle. All subjects managed exercise loads adequate for their age. Peak effort was associated with a significant reduction (mean 44.5% [range 10-95%]) in the RF (21.8±13.2 vs. 39.3%±14.7% at rest; p=0.0001). The absolute reduction in the RF at peak effort was greater among the subjects with severe aortic regurgitation (21.2% vs. 13.3% in those with moderate regurgitation; p=0.018). CONCLUSIONS: The RF becomes smaller during exercise in asymptomatic subjects with moderate or severe aortic regurgitation and preserved ventricular function.

El «patrón de De Winter» puede evolucionar a síndrome coronario agudo con elevación del segmento ST / The “De Winter Pattern” can progress to ST-segment elevation acute coronary syndrome

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