Low frequency of IL-10+ B cells in patients with atherosclerosis is related with inflammatory condition.

BACKGROUND AND AIMS: B cells involvement in animal models of atherosclerosis has been unequivocally established. However, the role of these cells in patients with atherosclerosis is almost unknown. Besides the production of antibodies, B cells can also exhibit regulatory functions mainly through IL-10. Here, we characterized human B cell subsets, their production of IL-10 in patients with atherosclerosis and their potential association with inflammation. METHODS: Patients with confirmed atherosclerotic events and controls with low cardiovascular risk were included. B cells subsets were determined in mononuclear cells (PBMC) using flow cytometry. PBMC were cultured ex vivo (5 h) and in vitro (48 h) to determine IL-10+ B cells and in some cases TNF-α+ and IFN-γ+ CD4+ T cells. The inflammatory state of the participants was determined through high sensitivity C reactive protein levels. RESULTS: Increase in percentage and number of plasmablasts was observed in patients with atherosclerosis compared with controls. A decreased frequency of IL-10+ B cells was observed in patients, both in ex vivo and in vitro cultures. This decrease was detected in transitional, memory, and plasmablast subsets. Interestingly, the reduction of IL-10+ B cells negatively and significantly correlated with the inflammatory condition of the studied subjects and associated with an increased frequency of TNF-α+ and IFN-γ+ CD4+ T cells. The blockade of IL-10R did not show further effect in T cells activation. CONCLUSIONS: There is an association between the inflammatory state and a reduction of IL-10+ B cells that could contribute to the development of atherosclerosis.

Factores de riesgo para mortalidad en falla cardiaca aguda. Análisis de árbol de regresión y clasificación / Risk factors for mortality in acute heart failure. A classification and regression tree analysis

Resumen Introducción: la estimación temprana del riesgo en falla cardiaca aguda puede ayudar en la toma de decisiones clínicas. Objetivo: identificar los factores de riesgo asociados a mortalidad intrahospitalaria en pacientes con falla cardiaca aguda. Métodos: análisis de una cohorte retrospectiva de pacientes mayores de 18 años ingresados a hospitalización por falla cardiaca aguda en un hospital de tercer nivel, entre los años 2012 y 2016. Resultados: se incluyeron 247 pacientes, con edad promedio de 62,8 años; predominó el sexo masculino con un 60%. El 84% de los pacientes tenía falla cardiaca con fracción de expulsión disminuida (mediana de 25%). La mortalidad intrahospitalaria fue de 9,3% y la acumulada a 30 días y 6 meses posterior al egreso hospitalario fue de 10,9 y 14,1%, respectivamente. Los dos predictores asociados a muerte intrahospitalaria fueron el nitrógeno ureico en sangre (BUN)> 37 mg/dl (OR: 10,8; 95% IC: 4,10-28,8) y la presión arterial sistólica (PAS) ≤ 125 mm Hg (OR: 3,42; 95% IC:1,15-10,0). El modelo de árbol de regresión y clasificación (CART) identificó como el mejor predictor de mortalidad los niveles elevados de BUN (≥ 32,5 mg/dl), seguido por la presión sistólica disminuida (< 97 mm Hg) y finalmente por los niveles elevados de creatinina (≥ 1,75 mg/dl). Conclusión: el análisis mediante el CART permite clasificar en forma temprana la probabilidad de muerte por un árbol de riesgo que incluye el BUN ≥ 32,5 mg/dl, la presión sistólica < 97 mm Hg y los niveles de creatinina ≥ 1,75 mg/dl.

Abstract Introduction: The early estimation of risk in acute heart failure may help in the taking of clinical decisions. Objective: To identify the risk factors associated with in-hospital mortality in patients with acute heart failure. Methods: An analysis was performed on a retrospective cohort of patients greater than 18 years admitted to a tertiary hospital due acute heart failure between the years 2010 and 2016. Results: A total of 247 patients were included, with a mean age of 62.8 years, and of which 60% were male. The large majority (84%) of the patients had heart failure with a reduced ejection fraction (median 25%). The in-hospital mortality was 9.3%, and the accumulated rate at 30 days and 6 months after hospital discharge was 10.9% and 14.1%, respectively. The two predictors associated with in-hospital death was a blood urea nitrogen (BUN) > 37 mg/dL (OR: 10.8; 95% CI: 4.10-28.8) and a systolic blood pressure (SBP) ≤ 125 mmHg (OR: 3.42; 95% CI: 1.15-10.0). The classification and regression tree (CART) model identified elevated levels of as the best predictor of mortality, followed by a decreased systolic pressure (< 97 mmHg), and finally due to elevated creatinine levels (≥ 1,75 mg/dL). Conclusion: The analysis using the classification and regression tree (CART) model can provide an early classification of the probability of death by a risk tree that includes BUN ≥ 32.5 mg/dL, systolic pressure <97 mm Hg, and creatinine levels ≥ 1.75 mg/dL.

Aneurisma del seno de Valsalva disecando hacia el septo interventricular en una paciente embarazada / Sinus of Valsalva aneurysm dissecting interventricular septum in pregnant patient

El aneurisma del seno de Valsalva es una entidad rara en la población general, con una incidencia de 0,14 al 3,5% en cirugías de corazón abierto; con un espectro clínico amplio y complicaciones cardiacas mecónicas o eléctricas que pueden ser fatales. En mujeres embarazadas también ha sido reportada esta entidad en unos cuantos casos en la literatura médica publicada. Se presenta un caso de una paciente gestante con aneurisma de seno de Valsalva, sus complicaciones y las medidas terapéuticas que se llevaron a cabo, ademós de una revisión del tema.

Sinus of Valsalva aneurysm is a rare entity in the general population, with an incidence of 0.14 to 3.5% in open heart surgery; with a broad clinical spectrum and mechanical or electrical cardiac complications that can be fatal. In pregnant women this entity has also been reported in a few cases in the medical literature. We present a case of a pregnant patient with sinus of Valsalva aneurysm, its complications and the therapeutic measures that were carried out, along with a review of the subject.

Invasión cardiaca de carcinoma sarcomatoide pulmonar a través de las venas pulmonares / Cardiac invasion of pulmonary sarcomatoid carcinoma through the pulmonary veins

Los tumores cardiacos son una entidad poco común; pueden ser resultado de metástasis o tumor primario originado en cualquiera de las cavidades cardiacas, o pueden llegar al corazón por invasión directa a través de las venas pulmonares de un tumor originario del pulmón, fenómeno que es aún más raro de acuerdo con lo reportado en la literatura hasta el día de hoy. Se publica el caso de una paciente que comenzó con deterioro de su clase funcional y con síntomas respiratorios; a quien con base en imágenes diagnósticas, se le detectó carcinoma sarcomatoide pulmonar que invadía el tracto de salida del ventrículo izquierdo a través de las venas pulmonares. Se discuten la incidencia de estos tumores, la sintomatología, las ayudas diagnósticas disponibles y las opciones de tratamiento.

Metastatic cardiac tumors are more common than primary ones; they may extend by contiguity through the pulmonary veins to the heart chambers. Although this is an unusual event, it has been reported with different types of tumors. We report the case of a patient who started with deterioration of her functional class and with respiratory symptoms. Diagnostic imaging showed a pulmonary sarcomatoid carcinoma invading the left ventricular outflow tract through the pulmonary vein. We discuss the impact of these tumors, symptoms, diagnostic aid that we have, as well as the treatment options.

Manifestaciones cardiacas del dengue: Reporte de una serie de casos durante la epidemia colombiana de 2010 / Cardiac manifestations of dengue: Report of a series of cases during the dengue epidemic of 2010 in Colombia

INTRODUCCIÓN: el dengue es la enfermedad viral transmitida por vectores de diseminación más frecuente en el mundo. Su espectro clínico incluye las manifestaciones atípicas, entre ellas el compromiso cardiaco, del cual sólo se han reportado pocas series de casos en la literatura. OBJETIVO: reportar las características clínicas de los pacientes atendidos por casos confirmados por serología de dengue con manifestaciones cardiovasculares en un centro de referencia cardiovascular colombiano durante la epidemia de 2010. METODOLOGÍA: estudio observacional, descriptivo, prospectivo, en el que se incluyeron los pacientes que consultaron al servicio de urgencias, a quienes se les realizó un diagnóstico confirmado de dengue y tuvieron manifestaciones cardiovasculares de la enfermedad. RESULTADOS: se encontraron 7 pacientes; el 50% no tenía antecedentes previos de enfermedad cardiovascular. Los trastornos del ritmo fueron la manifestación cardiaca más frecuente (42,8%), entre ellos la fibrilación auricular de novo (14,2%), el bloqueo auriculoventricular completo y transitorio (14,2%), la bradicardia sinusal concomitante con derrame pericárdico (14,2%) y la disfunción ventricular leve (28,5%); un paciente presentó un síndrome coronario agudo con elevación de ST durante la infección y dos descompensación aguda de insuficiencia cardiaca. No se reportaron muertes. CONCLUSIÓN: la incidencia de las complicaciones cardiacas asociadas a la infección por dengue varía de una serie a otra y su fisiopatología no se conoce por completo. Durante la epidemia que se desató en Colombia en 2010 se encontraron pocos casos de manifestaciones cardiovasculares pero con una morbilidad importante que debe alertar respecto a su identificación temprana.

INTRODUCTION: dengue is the most common worldwide viral disease transmitted by dissemination vectors. Its clinical spectrum comprehends atypical manifestations including cardiac involvement, from which only few series of cases have been reported in the literature. OBJECTIVE: to report the clinical characteristics of patients treated for serologically confirmed cases of dengue with cardiovascular events in a Colombian cardiovascular referral center during the epidemic of 2010. METHODS: an observational, descriptive, prospective study, which included patients presenting to the emergency service and had a confirmed diagnosis of dengue with cardiovascular manifestations of the disease. RESULTS: 7 patients met the inclusion criteria. 50% had no prior history of cardiovascular disease. Rhythm disorders were the most common cardiac manifestation (42.8%), including de novo atrial fibrillation (14.2%), complete atrioventricular block and transient (14.2%), sinus bradycardia concomitant with pericardial effusion (14.2%) and mild ventricular dysfunction (28.5%). One patient had an acute coronary syndrome with ST elevation during infection and two had acute decompensated heart failure. No deaths were reported. CONCLUSION: the incidence of cardiac complications associated with dengue infection varies from one series to another and its pathophysiology is not completely understood. During the epidemic that occurred in Colombia in 2010 there were few cases with cardiovascular symptoms but with significant morbidity that should alert regarding its early identification.

Resección de fibroelastoma papilar mitral mediante cirugía mínimamente invasiva en paciente con accidente cerebrovascular / Mitral papillary fibroeslastoma resection through minimally invasive surgery in a patient with stroke

Paciente quien consultó con síntomas neurológicos y se realizó diagnóstico de accidente cerebrovascular embólico cuya etiología consistió en un tumor cardíaco de la válvula mitral (fibroelastoma) con confirmación histológica. Fue intervenido quirúrgicamente mediante técnica mínimamente invasiva a través del tórax, con excelente evolución, sin infección ni requerimientos sanguíneos; no presentó secuelas valvulares ni neurológicas. Se reportó reincorporación temprana a la vida laboral.

We report the case of a patient who consulted with neurological symptoms and was diagnosed as embolic stroke, whose etiology was a mitral valve tumor (fibroeslastoma) histologically confirmed. The patient underwent surgery through minimally invasive technique through the chest, with excellent evolution, without infection or blood requirements; there were no valvular or neurological sequelae. An early return to working life was reported.

Arteria coronaria descendente anterior doble: reporte de un caso y revisión de la literatura / Dual left anterior descending coronary artery: a case report and literature review

La arteria coronaria descendente anterior es la arteria coronaria con el trayecto más constante; sin embargo en algunas ocasiones puede presentarse un sistema doble. Se reporta y se realiza una revisión de la literatura de un caso de un paciente con arteria coronaria descendente anterior doble tipo 1, con bloqueo de rama izquierda pero sin lesiones ateromatosas significativas.

The left anterior descending coronary artery has one of the most constant anatomy course of all coronary arteries. Rarely however, interventional cardiologists might be facing with a dual left anterior descending artery during routine angiography. A case of a patient presenting with left bundle branch block and a coronary angiography showing a rare anatomic variant of a type 1, dual left anterior descending coronary artery is reported. The available literature was also reviewed.

Unfractioned heparin for treatment of sepsis: A randomized clinical trial (The HETRASE Study).

OBJECTIVE: The primary aims of this study were to determine the effects of heparin on length of stay and change from baseline multiple organ dysfunction (MOD) score. Secondary objectives were to estimate the effects of heparin on 28-day all-cause mortality, and to determine the possible effect modification on 28-day all-cause mortality, in subgroups defined by site of infection and baseline values of Acute Physiology and Chronic Health Evaluation II score, MOD score, and d-dimer. DESIGN: Randomized, double-masked, placebo-controlled, single-center clinical trial, testing low dose continuous infusion of unfractioned heparin (UFH) as complementary treatment for sepsis. SETTING: Five hundred fifty bed University Hospital and referral center in Medellín, Columbia. PATIENTS: Three hundred nineteen patients admitted at the emergency room with signs indicative of sepsis. INTERVENTIONS: Patients were randomly assigned to receive placebo or UFH (500 units/hour for 7 days). MEASUREMENTS AND MAIN RESULTS: The median length of stay in patients discharged alive in the placebo group was 12.5 days (interquartile range = 8-20), and 12 days (interquartile range = 8-19.5) in the heparin group (p = 0.976). The MOD score improved equally in the two treatments arms with an average decline of 0.13 and 0.11 per day for the placebo and heparin groups (p = 0.240), respectively. The overall 28-day mortality was 16% in the placebo group and 14% in the heparin group (p = 0.652). Subgroup analyses did not show any statistically significant reduction in 28-day mortality with UFH. There was only one serious adverse event on a patient who received heparin but it was fully resolved without complications. CONCLUSIONS: Our findings suggested that UFH may be a feasible and safe intervention in sepsis. However, this study was not able to demonstrate a beneficial effect on the chosen primary outcomes or in the 28-day mortality rate.

A randomized clinical trial of unfractioned heparin for treatment of sepsis (the HETRASE study): design and rationale [NCT00100308].

INTRODUCTION: Infection promotes coagulation via a large number of molecular and cellular mechanisms, and this procoagulant activity has boosted basic and clinical research using anticoagulant molecules as therapeutic tools in sepsis. Heparin, which is a naturally occurring proteoglycan that acts by reducing thrombin generation and fibrin formation, has not been rigorously tested in a randomized clinical trial. METHODS: Randomized, double-masked, placebo-controlled, single-center clinical trial. Patients are recruited through the emergency room at Hospital Universitario San Vicente de Paul. This is a 650-bed University Hospital in Medellín, Colombia and is a referral center for a region with approximately 3 million habitants. The recruitment process started on July 2005 and will finish on June 2007. Patients aged 18 years or older, males or females, hospitalized with clinically or microbiological confirmed sepsis, have been included. The interventions are unfractioned heparin in low dose continuous infusion (500 units per hour for 7 days) or placebo, additionally to the standard of care for sepsis patients in Colombia. RESULTS: Our primary aims are to estimate the effects of heparin on hospital length of stay and change from baseline Multiple Organ Dysfunction (MOD) score. Secondary objectives are to estimate the effects of heparin on 28-day all-cause mortality, and to estimate the possible effect modification on 28-day all-cause mortality, in subgroups defined by source and site of infection, and baseline values of APACHE II score, MOD score and D-dimer. CONCLUSION: The available literature in animal and human research, and the understanding of the molecular biology regarding inflammation and coagulation, supports a randomized clinical trial for the use of heparin in sepsis. Our study will provide appropriate power to detect differences in valid surrogate outcomes, and it will explore important preliminary data for efficacy regarding the clinical end-point of mortality.