[Rapid aspirin desensitization in patients with a history of aspirin hypersensitivity requiring coronary angioplasty. Report of four cases]. / Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria. Reporte de cuatro casos.

Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria: Reporte de cuatro casos / Rapid aspirin desensitization in patients with a history of aspirin hypersensitivity requiring coronary angioplasty: Report of four cases

Background: Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

[Non compaction cardiomyopathy: a series of 15 cases]. / Miocardiopatía no compactada: una serie de 15 casos.

BACKGROUND: Non compaction cardiomyopathy is a rare disorder caused by the arrest of myocardial compaction during embryogenesis, leading to a non compacted endocardial layer with marked hypertrabeculation and deep recesses. AIM: To report the clinical and echocardiographic characteristics of a series of 15 adult patients with non-compaction cardiomyopathy. PATIENTS AND METHODS: We included a total of 15 patients aged 52 ± 17 years (40% males) diagnosed at our echocardiography laboratory between January 2001 and July 2010. RESULTS: The form of presentation was heart failure in 53% of subjects, syncope in 20%o, ventricular arrhythmias in 13%o and stroke in 7%>. Left ventricular end-diastolic diameter was 66 ± 11 mm and estimated ejection fraction was 27 ± 10%>. Apical and/or mid-ventricular segments of the left ventricle were involved in all the cases. Pulmonary hypertension was present in 40%o. The average follow-up was 19 months and no patient died during this period. Sixty seven percent of the patients had manifestations of heart failure, 27%o presented sustained ventricular arrhythmias and 20%> had atrial fibrillation or flutter, whereas 13%o had cerebral embolic events. An automated internal cardioverter defibrillator was implanted in 47%o of patients. CONCLUSIONS: Non-compaction cardiomyopathy is associated with high cardiovascular morbidity. The diagnosis is made in advanced stages of the disease, with significant dilation and ventricular dysfunction.

Miocardiopatía no compactada: una serie de 15 casos / Non compaction cardiomyopathy: a series of 15 cases

Background: Non compaction cardiomyopathy is a rare disorder caused by the arrest of myocardial compaction during embryogenesis, leading to a non compacted endocardial layer with marked hypertrabeculation and deep recesses. Aim: To report the clinical and echocardiographic characteristics of a series of 15 adult patients with non-compaction cardiomyopathy. Patients and Methods: We included a total of 15 patients aged 52 ± 17 years (40 percent males) diagnosed at our echocardiography laboratory between January 2001 and July 2010. Results: Theform of presentation was heart failure in 53 percent of subjects, syncope in 20 percento, ventricular arrhythmias in 13 percento and stroke in 7 percent>. Left ventricular end-diastolic diameter was 66 ±11 mm and estimated ejection fraction was 27 ± 10 percent>. Apical and/or mid-ventricular segments of the left ventricle were involved in all the cases. Pulmonary hypertension was present in 40 percento. The average follow-up was 19 months and no patient died during this period. Sixty seven percent ofthe patients had manifestations of heart failure, 27 percento presented sustained ventricular arrhythmias and 20 percent> had atrial fibrillation orflutter, whereas 13 percento had cerebral embolic events. An automated internal cardioverter defibrillator was implanted in 47 percento of patients. Conclusions: Non-compaction cardiomyopathy is associated with high cardiovascular morbidity. The diagnosis is made in advanced stages of the disease, with significant dilation and ventricular dysfunction.

Miocardiopatía dilatada secundaria a enfermedad celíaca: Caso clínico / Dilated cardiomyopathy in celiac disease: Report of one case

There is an increased incidence of celiac disease in patients with idiopathic dilated cardiomyopathy. We report a 4 7 year-old female presenting with heart failure secondary to dilated cardiomyopathy of unknown etiology. During the five months following the first hospitalization the patient had multiple hospital admissions due to decompensate heart failure. Due to a history of intermittent diarrhea and weight loss, a celiac disease was suspected. Antiendomysial antibodies were positive and there was a villous atrophy in duodenal mucosa. A gluten free diet was started with a concomitant recovery of her functional capacity. After one month of gluten free diet a new echocardiogram showed a normal left ventricle and systolic function.

[Dilated cardiomyopathy in celiac disease: report of one case]. / Miocardiopatía dilatada secundaria a enfermedad celíaca: Caso clínico.

There is an increased incidence of celiac disease in patients with idiopathic dilated cardiomyopathy. We report a 4 7 year-old female presenting with heart failure secondary to dilated cardiomyopathy of unknown etiology. During the five months following the first hospitalization the patient had multiple hospital admissions due to decompensate heart failure. Due to a history of intermittent diarrhea and weight loss, a celiac disease was suspected. Antiendomysial antibodies were positive and there was a villous atrophy in duodenal mucosa. A gluten free diet was started with a concomitant recovery of her functional capacity. After one month of gluten free diet a new echocardiogram showed a normal left ventricle and systolic function.

Angina secundaria a lesión de tronco coronario izquierdo post trasplante cardiaco: Evidencias de reinervación simpática tardía / Angina after a heart transplant with evidence of late sympathetic reinnervation: Report of one case

We report a 56 years-old man presenting with chest pain with exercise, seven years after an orthotopic heart transplant. A coronary angiography showed an atherosclerotic lesion in the common left main coronary artery with more than 90 percent obstruction. The lesion was successfully treated with a transluminal angioplasty with stenting. A 131-1 metaiodobenylguanidine (MIBG) scan demonstrated sympathetic reinnervation. Sixteen months later, due to progression of allograft vasculopathy, coronary artery bypass was required.

[Oxidative stress and inflammation in heart failure: mechanisms of damage and therapeutic alternatives]. / Estrés oxidativo e inflamación en insuficiencia cardiaca: Mecanismos de daño y alternativas terapéuticas.

Despite advances in treatment, chronic heart failure still is associated with a poor prognosis and remains a leading cause of cardiovascular death. Cumulating evidence suggests that imbalances in redox state lead to a higher generation of reactive oxygen species. This phenomenon, along with pro-inflammatory cytokine activation and extra cellular matrix alterations with reactive fibrosis, play an important role in the pathogenesis and progression of heart failure, through the development of endothelial and myocardial dysfunction. The understanding of the underlying phenomena and the metabolic pathways involved will allow further development of therapies aiming to change the natural history of heart failure.

Estrés oxidativo e inflamación en insuficiencia cardiaca: Mecanismos de daño y alternativas terapéuticas / Oxidative stress and inflammation in heart failure: Mechanisms of damage and therapeutic alternatives

Despite advances in treatment, chronic heart failure still is associated with a poor prognosis and remains a leading cause of cardiovascular death. Cumulating evidence suggests that imbalances in redox state lead to a higher generation of reactive oxygen species. This phenomenon, along with pro-inflammatory cytokine activation and extra cellular matrix alterations with reactive fibrosis, play an important role in the pathogenesis and progression of heart failure, through the development of endothelial and myocardial dysfunction. The understanding of the underlying phenomena and the metabolic pathways involved will allow further development of therapies aiming to change the natural history of heart failure.

[Angina after a heart transplant with evidence of late sympathetic reinnervation. Report of one case]. / Angina secundaria a lesión de tronco coronario izquierdo post trasplante cardiaco: Evidencias de reinervación simpática tardía.

We report a 56 years-old man presenting with chest pain with exercise, seven years after an orthotopic heart transplant. A coronary angiography showed an atherosclerotic lesion in the common left main coronary artery with more than 90% obstruction. The lesion was successfully treated with a transluminal angioplasty with stenting. A 131-1 metaiodobenylguanidine (MIBG) scan demonstrated sympathetic reinnervation. Sixteen months later, due to progression of allograft vasculopathy, coronary artery bypass was required.

[Predictors of hospital death and prolonged hospitalization in patients with cardiac failure in Chilean hospitals]. / Predictores de mortalidad intrahospitalaria y hospitalización prolongada en la insuficiencia cardíaca: resultados preliminares del registro nacional de insuficiencia cardíaca. Grupo ICARO.

BACKGROUND: Heart failure (HF) is one of the most common causes for hospital admission. AIM: To evaluate clinical predictors of mortality and prolonged hospital stay among patients admitted for HF in Chilean hospitals. PATIENTS AND METHODS: Prospective registry of 14 centers. Patients admitted for HF in functional class III and IV were included. Epidemiological, clinical data, functional class, decompensation cause, electrocardiogram, echocardiogram, treatment and evolution were registered. The endpoint was hospital death and hospital stay greater than 10 days. RESULTS: Data from 646 patients (mean age 69+/-13 years, 56% men) was collected. The main etiologies of HF were hypertensive in 29.6%, ischemic in 27.1% and valvular in 20%. Mean hospital stay was 10+/-9 days and mortality was 5.6%. Independent predictors of death and prolonged hospital stay were serum sodium <130 mEq/L at admission (odds ratio (OR) 2.6, confidence interval (CI) = 1.2-5.9), serum albumin <3 g/dL (OR 3.2, CI= 1.42-7.2) and a history of hypertension (OR 1.98, CI = 1.1-3.85). The model predicted correctly the occurrence of the endpoint in 67% of cases. CONCLUSIONS: In patients admitted for worsening HF, low serum sodium, decreased serum albumin on admission and a history of hypertension increase the risk for in-hospital death and prolonged hospital stay.

Estado actual de los sistemas de soporte circulatorio mecánico: State of the art / Circulatory mechanical support. State of the art

Despite advances in medical treatment, the prognosis of advanced heart failure remains poor. The number of hospitalizations for heart failure exacerbations continues to increase and most patients will ultimately die of complications related to heart failure. Implantable left ventricular assist devices (LVAD) are currently in use throughout the world with increasing frequency. This paper is a comprehensive review about mechanical support, focusing on a general description of the differents LVAD, complications and mortality.

Predictores de mortalidad intrahospitalaria y hospitalización prolongada en la insuficiencia cardíaca: resultados preliminares del registro nacional de insuficiencia cardíaca. Grupo ICARO / Predictors of hospital death and prolonged hospitalization in patients with cardiac failure in Chilean hospitals

Background: Heart failure (HF) is one of the most common causes for hospital admission. Aim: To evaluate clinical predictors of mortality and prolonged hospital stay among patients admitted for HF in Chilean hospitals. Patients and Methods: Prospective registry of 14 centers. Patients admitted for HF in functional class III and IV were included. Epidemiological, clinical data, functional class, decompensation cause, electrocardiogram, echocardiogram, treatment and evolution were registered. The endpoint was hospital death and hospital stay greater than 10 days. Results: Data from 646 patients (mean age 69±13 years, 56 percent men) was collected. The main etiologies of HF were hypertensive in 29.6 percent, ischemic in 27.1 percent and valvular in 20 percent. Mean hospital stay was 10±9 days and mortality was 5.6 percent. Independent predictors of death and prolonged hospital stay were serum sodium <130 mEq/L at admission (odds ratio (OR) 2.6, confidence interval (CI)= 1.2-5.9), serum albumin <3 g/dL (OR 3.2, CI= 1.42-7.2) and a history of hypertension (OR 1.98, CI=1.1-3.85). The model predicted correctly the occurrence of the endpoint in 67 percent of cases. Conclusions: In patients admitted for worsening HF, low serum sodium, decreased serum albumin on admission and a history of hypertension increase the risk for in-hospital death and prolonged hospital stay.

Asistencia ventricular mecánica como puente al trasplante en pacientes en shock cardiogénico: Experiencia preliminar en Chile con ABIOMED BVS 5000® / Ventricular assist device as a bridge to transplant in patients with cardiogenic shock: Report of four patients

Hospitalization and death due to heart failure and cardiogenic shock is frequent and currently is increasing among the adult population. Although cardiac transplantation is the most effective treatment in patients with end-stage heart failure, its availability is limited. While waiting for transplantation, some patients become refractory to treatment and deteriorate progressively. Secondary multi-organ damage could highly compromise the transplant success and also could contraindicate it. Mechanical ventricular assist devices allow reestablishing normal cardiac output and they have been used as a bridge to recovery and transplantation. We report four patients that underwent mechanical ventricular support using the ABIOMED BVS 5000® system as a bridge for transplantation. Two patients were connected to biventricular assistance; a third patient was connected to a left ventricular support and the fourth to a right ventricular support. Three were successfully transplanted and one died of refractory non-cardiogenic shock. There were no complications related to the support system, such as infection, hemorrhage or stroke. In our experience, the ABIOMED BVS 5000® was an effective strategy as a bridge to heart transplant in patients in cardiogenic shock.

[Characteristics of heart failure with preserved ejection fraction: results of the Chilean national registry of heart failure, ICARO]. / Características de la insuficiencia cardíaca en pacientes con fracción de eyección preservada: resultados del registro Nacional de insuficiencia Cardíaca, grupo ICARO.

BACKGROUND: Heart failure (HF) with preserved ejection fraction (EF) is a condition of growing interest due to its high prevalence and difficult management. AIM: To evaluate the clinical profile of patients hospitalized with HF and preserved EF in Chilean hospitals. MATERIAL AND METHODS: Prospective registry of 15 centers. Among 649 patients hospitalized in functional class III and IV, an echocardiogram was performed to 353. Preserved EF was defined quantitatively as an EF >50%. RESULTS: Out the 353 patients, 45% presented an EF >50%. Mean age in patients with EF >50 and -50% was 66+/-13 and 67+/-13 years, respectively. Among patients with HF and EF >50%, the proportion of women was higher (73.7 and 36.3%, p <0.001), the proportion of patients with a history of hypertension (76.8 and 65.5%, p <0.05) and the presence of atrial fibrillation was also higher (62.3 and 47.8%, p <0.01) and a history of myocardial infarction was lower (17.1 and 29.5%, p <0.05). The diastolic diameter of the left ventricle was significantly lower in HF with preserved EF (51.0+10 and 63.5+10 mm respectively, p <0.001). No differences in the length of hospital stay and mortality were observed between HF with depressed and preserved EF. Female gender was an independent predictor for the presence of HF with preserved EF (Odds ratio: 2.62; confidence intervals: 1.1-6.1). CONCLUSIONS: HF and preserved EF is common among hospitalized patients, particularly in women and subjects with a history of hypertension and atrial fibrillation. Hospitalization length and mortality were similar in patients with either preserved or depressed EF.

Características de la insuficiencia cardíaca en pacientes con fracción de eyección preservada: Resultados del Registro Nacional de Insuficiencia Cardíaca, Grupo ICARO / Characteristics of heart failure with preserved ejection fraction: Results of the Chilean National Registry of Heart Failure, ICARO

Background: Heart failure (HF) with preserved ejection fraction (EF) is a condition of growing interest due to its high prevalence and difficult management. Aim: To evaluate the clinical profile of patients hospitalized with HF and preserved EF in Chilean hospitals. Material and Methods: Prospective registry of 15 centers. Among 649 patients hospitalized in functional class III and IV, an echocardiogram was performed to 353. Preserved EF was defined quantitatively as an EF >50%. Results: Out the 353 patients, 45% presented an EF >50%. Mean age in patients with EF >50 and ­50% was 66±13 and 67±13 years, respectively. Among patients with HF and EF >50%, the proportion of women was higher (73.7 and 36.3%, p <0.001), the proportion of patients with a history of hypertension (76.8 and 65.5%, p <0.05) and the presence of atrial fibrillation was also higher (62.3 and 47.8%, p <0.01) and a history of myocardial infarction was lower (17.1 and 29.5%, p <0.05). The diastolic diameter of the left ventricle was significantly lower in HF with preserved EF (51.0+10 and 63.5+10 mm respectively, p <0.001). No differences in the length of hospital stay and mortality were observed between HF with depressed and preserved EF. Female gender was an independent predictor for the presence of HF with preserved EF (Odds ratio: 2.62; confidence intervals: 1.1-6.1). Conclusions: HF and preserved EF is common among hospitalized patients, particularly in women and subjects with a history of hypertension and atrial fibrillation. Hospitalization length and mortality were similar in patients with either preserved or depressed EF.

Utilidad de isosorbide sublingual en la reversibilidad de la hipertensión pulmonar reactiva, en pacientes candidatos a trasplante cardíaco / Usefulness of sublingual isosorbide to assess the reversibility of pulmonary hypertension in cardiac transplant candidates

Background: Continuous infusion of short life vasodilators are employed to test reversibility of pulmonary hypertension in cardiac transplant candidates. Sublingual isosorbide administration has not been described in the literature and it might be a simpler alternative. Aim: To evaluate sublingual isosorbide administration as a test of reversibility of pulmonary hypertension in heart failure. Patients and Methods: Prospective evaluation of patients referred for cardiac transplant evaluation. Patients underwent right catheterization for hemodynamic measurements at baseline and after repeated doses of 5 mg sublingual isosorbide every 5 minutes until observing a decrease in pulmonary vascular resistance decrease or symptomatic hypotension. Results: Twenty one patients, 18 men, age 49±15 years, were studied. Fourteen (66%) were transplanted. The mean sublingual isosorbide dose was 15±5 mg. After isosorbide administration, there was a significant decrease in mean arterial pressure (80±8.5 to 71±6.6 mmHg, p <0.0001), mean pulmonary artery pressure (38±11 to 26±7.8 mmHg, p <0.0001), systemic vascular resistance (1540±376 to 1277±332 dyn*s/cm5 p <0.001), pulmonary vascular resistance (3.5±2.2 to 2,5±1.6 Wood Units, p <0.05) and transpulmonary gradient (13±7 a 10±4 mmHg, p <0.004). The cardiac output increased from 3.96±0.7 to 4.38±0.9 L/min, p=0.05. The relation between pulmonary and systemic vascular resistance before and after isosorbide was 0.17 and 0.15, respectively (p=0.04). One transplanted patient with partial reversibility of pulmonary hypertension developed acute right heart failure. Conclusions: Sublingual isosorbide administration is useful and well tolerated to evaluate the reversibility of pulmonary hypertension prior cardiac transplant.

Biomarcadores coronarios y evolución clínica alejada en pacientes con síndromes coronarios agudos sin elevación del segmento ST / Coronary biomarkers and long-term clinical outcome in acute coronary syndrome without ST segment elevation

Background: The use of new biomarkers improved risk stratification for patients with acute coronary syndromes (ACS). Aim: To evaluate the relationship between multiple biomarkers and long-term clinical outcome in ACS without ST segment elevation. Patients and Methods: Consecutive patients presenting with suspected ACS were studied. On admission to the emergency room, serum was obtained to determine highly sensitive C reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), lipoprotein (a) (LPa) and soluble P selectin (sPS). Clinical endpoints were mortality and a composite endpoint of major adverse cardiovascular events (MACE) including death, re-infarction, and angina. Results: Seventy patients, aged 63±13 years, 54 males, were studied. Final diagnosis was unstable angina in 71% and non-ST-segment elevation myocardial infarction in 29%. MACE and mortality rate were 17% and 5.8%, respectively. We found higher plasma levels of hsCRP, ESR and Lp(a) in patients with MACE (p=0.032, p=0.015 and p=0.010, respectively). Plasma levels of hsCRP and ESR were also higher in patients who died during the follow up (p=0.002 y p=0.045, respectively). Conclusion: Plasma levels of inflammatory markers and atherosclerosis biomarkers are associated with a worse long-term clinical outcome in ACS without ST segment elevation. The inclusion of these biomarkers in the routine blood test on admission, could improve risk stratification of patients with ACS in the future.

[Coronary biomarkers and long-term clinical outcome in acute coronary syndrome without ST segment elevation]. / Biomarcadores coronarios y evolución clínica alejada en pacientes con síndromes coronarios agudos sin elevación del segmento ST.

BACKGROUND: The use of new biomarkers improved risk stratification for patients with acute coronary syndromes (ACS). AIM: To evaluate the relationship between multiple biomarkers and long-term clinical outcome in ACS without ST segment elevation. PATIENTS AND METHODS: Consecutive patients presenting with suspected ACS were studied. On admission to the emergency room, serum was obtained to determine highly sensitive C reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), lipoprotein (a) (LPa) and soluble P selectin (sPS). Clinical endpoints were mortality and a composite endpoint of major adverse cardiovascular events (MACE) including death, re-infarction, and angina. RESULTS: Seventy patients, aged 63+/-13 years, 54 males, were studied. Final diagnosis was unstable angina in 71% and non-ST-segment elevation myocardial infarction in 29%. MACE and mortality rate were 17% and 5.8%, respectively. We found higher plasma levels of hsCRP, ESR and Lp(a) in patients with MACE (p=0.032, p=0.015 and p=0.010, respectively). Plasma levels of hsCRP and ESR were also higher in patients who died during the follow up (p=0.002 y p=0.045, respectively). CONCLUSION: Plasma levels of inflammatory markers and atherosclerosis biomarkers are associated with a worse long-term clinical outcome in ACS without ST segment elevation. The inclusion of these biomarkers in the routine blood test on admission, could improve risk stratification of patients with ACS in the future.

Insuficiencia cardíaca en hospitales chilenos: resultados del Registro Nacional de Insuficiencia Cardíaca, Grupo ICARO / Cardiac failure in Chilean hospitals: results of the National Registry of Heart Failure, ICARO

Background: Heart failure (HF) is a major public health problem. In Chile hospitalized patients due to HF have not been characterized. Aim: To evaluate clinical profile and outcome of patients hospitalized for heart failure in Chilean hospitals. Patients and Methods: Prospective registry of 14 centers. Patients hospitalized for HF in functional class III and IV were included. Epidemiological and clinical data, functional class, type of presentation, decompensation cause, electrocardiogram, echocardiogram, treatment and evolution were registered. Results: Three hundred seventy two patients aged 69±13 years old, 59 percent men, were assessed. The main etiologies of HF were ischemic in 31.6 percent, hypertensive in 35.2 percent, valvular in 14.9 percent and idiopathic in 7.4 percent. There was a history of hypertension 69 percent, diabetes in 35 percent, myocardial infarction in 22 percent, atrial fibrillation (AF) in 28 percent. The presentation form of HF was chronic decompensated in 86 percent, acute in 12 percent, refractory in 2 percent. The causes of decompensation were non compliance with diet or medical prescriptions in 28 percent, infections in 22 percent and AF 17 percent. ECG showed AF in 36 percent and left bundle branch block in 16 percent. Echocardiography was performed in 52 percent of the patients, 69 percent had left ventricular ejection fraction <40 percent. On admission, 39 percent received angiotensin converting enzyme (ACE) inhibitors, 15 percent beta-blocker, 25 percent digoxin, 16 percent spironolactone and 53 percent furosemide. The mean hospital stay was 11±10 days and mortality was 4.5 percent. Conclusions: The elderly is the age group most commonly admitted to hospital due to HF. The main etiologies were ischemic and hypertensive. The main causes for decompensations were noncompliance with diet or medical prescriptions and infections. A significant proportion had a relatively well preserved ventricular systolic function (Rev Méd Chile 2004; 132: 655-62).