Aneurisma del septo membranoso como causa excepcional de bloqueo auriculoventricular paroxístico / Aneurysmal membranous septum as an exceptional cause of paroxysmal atrioventricular block

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Evolución de pacientes ancianos ingresados por estenosis aórtica severa y rechazados para intervención quirúrgica / Outcomes of elderly patients admitted to hospital due to severe aortic stenosis and rejected for surgical intervention

Introducción. La evolución natural de la estenosis aórtica severa sintomática no intervenida presenta un pronóstico infausto. Nos proponemos estudiar en este análisis las variables clínicas, ecográficas y analíticas que pudieran estar asociadas con el pronóstico vital en este subgrupo de pacientes. Material y métodos. Estudio retrospectivo de pacientes ingresados en nuestro centro entre 2004 y 2008 por síntomas asociados a la presencia de una estenosis aórtica severa y no considerados para intervención quirúrgica. Se analizaron datos demográficos, enfermedades concomitantes, datos ecocardiográficos (fracción de eyección, gradiente transvalvular, área valvular), analíticos (hemoglobina, creatinina, péptido natriurético auricular) y el cálculo del euroscore logístico Resultados. Fueron recogidos 49 pacientes (73,5% mujeres), con una edad media de 82,2±5,5 años. La mediana de seguimiento fue 396,0 días, rango intercualítico 99,5–731,0 días, con una mortalidad del 75,5%. En el análisis multivariante tan solo la medida de la fracción de eyección de ventrículo izquierdo por ecocardiografía fue un importante predictor en cuanto a la esperanza de vida (FE 35–50%: HR 3,74, IC 95% 1,11–12,65, p=0,034; FE<35%: HR 6,76, IC 95% 1,86–24,52, p=0,004). Conclusión. La esperanza de vida en pacientes con estenosis aórtica severa sintomática y no intervenidos se encuentra muy limitada, con una alta mortalidad durante el primer año. La fracción de eyección se asocia de forma significativa con el pronóstico en este tipo de pacientes(AU)

Introduction. The natural outcome of untreated severe symptomatic aortic stenosis in the elderly patient is extremely poor. In this analysis we studied the clinical, ultrasound and analytical variables, that could be associated with the vital prognosis in this patient sub-group. Material and methods. A retrospective study of patients admitted to our hospital between 2004 and 2008 due to symptoms associated with the presence of a severe aortic stenosis and were not considered for surgery. Demographic, concomitant diseases, ultrasound (ejection fraction, transvalvular gradient, valve area) and laboratory analytical data (haemoglobin, creatinine, atrial natriuretic peptide) were analysed and the logistic euroscore was calculated. Results. A total of 49 patients were included (73.5% women), with a mean age of 82.2±5.5 years. The median follow up was 396.0 days, interquartile range 99.5–731.0 days, with a mortality of 75.5%. In the multivariate analysis, only the left ventricular ejection fraction measured by ultrasound was an important predictor as regards life expectancy (EF 35–50%: HR 3.74, IC 95% CI; 1.11–12.65, P=0.034; EF<35%: HR 6.76, IC 95% CI; 1.86–24.52, p=0.004). Conclusion. The life expectancy of elderly patients with untreated severe symptomatic aortic stenosis is very limited, with a high mortality during the first year. The ejection fraction is significantly associated with the prognosis in these patients(AU)

[Outcomes of elderly patients admitted to hospital due to severe aortic stenosis and rejected for surgical intervention]. / Evolución de pacientes ancianos ingresados por estenosis aórtica severa y rechazados para intervención quirúrgica.

INTRODUCTION: The natural outcome of untreated severe symptomatic aortic stenosis in the elderly patient is extremely poor. In this analysis we studied the clinical, ultrasound and analytical variables, that could be associated with the vital prognosis in this patient sub-group. MATERIAL AND METHODS: A retrospective study of patients admitted to our hospital between 2004 and 2008 due to symptoms associated with the presence of a severe aortic stenosis and were not considered for surgery. Demographic, concomitant diseases, ultrasound (ejection fraction, transvalvular gradient, valve area) and laboratory analytical data (haemoglobin, creatinine, atrial natriuretic peptide) were analysed and the logistic euroscore was calculated. RESULTS: A total of 49 patients were included (73.5% women), with a mean age of 82.2±5.5 years. The median follow up was 396.0 days, interquartile range 99.5-731.0 days, with a mortality of 75.5%. In the multivariate analysis, only the left ventricular ejection fraction measured by ultrasound was an important predictor as regards life expectancy (EF 35-50%: HR 3.74, IC 95% CI; 1.11-12.65, P=0.034; EF<35%: HR 6.76, IC 95% CI; 1.86-24.52, p=0.004). CONCLUSION: The life expectancy of elderly patients with untreated severe symptomatic aortic stenosis is very limited, with a high mortality during the first year. The ejection fraction is significantly associated with the prognosis in these patients.

[Normal conventional electrocardiogram with negative pharmacological stress test does not rule out Brugada syndrome]. / El electrocardiograma convencional normal con test de provocación farmacológico negativo no descarta el síndrome de Brugada.

The diagnosis of Brugada syndrome, or right bundle-branch block with an elevated ST segment and negative T waves in V1-3, is obscured by the transitory normalization of the electrocardiogram, which can be unmasked by administering sodium-channel blockers. It has been recently reported that the condition can be underdiagnosed if only conventional precordial leads are used. We present the cases of two asymptomatic patients, a mother and son, with a family history of sudden cardiac death in first-degree relatives. Baseline ECGs obtained in conventional leads and one and two intercostal spaces above conventional electrode sites were similar, normal in the mother and saddle-like in the son. A flecainide stress test elicited the characteristic pattern of Brugada syndrome in both patients, but only in the high leads. Pharmacological stress testing with conventional precordial lead recordings does not rule out Brugada syndrome. We recommend that ECG recordings should include leads in the second and third intercostal spaces.

El electrocardiograma convencional normal con test de provocación farmacológico negativo no descarta el síndrome de Brugada / Normal conventional electrocardiogram with negative pharmalogical stress test does not rule out Brugada syndrome

El diagnóstico del síndrome de Brugada, bloqueo de rama derecha con segmento ST elevado y ondas T negativas de V1-3, se encuentra dificultado por la normalización transitoria del electrocardiograma, y puede ser desenmascarado por los bloqueadores de los canales de sodio. Recientemente se ha comunicado su posible infravaloración con la sola utilización de las derivaciones precordiales convencionales. Presentamos los casos de 2 pacientes asintomáticos, madre e hijo, con antecedentes familiares de primer grado de muerte súbita. Los ECG basales en las derivaciones precordiales convencionales y en uno y dos espacios intercostales por encima fueron similares, normal en la madre y en 'silla de montar' en el hijo. Tras test de flecainida, ambos desarrollaron el patrón electrocardiográfico típico del síndrome de Brugada exclusivamente en las derivaciones superiores. El test de provocación farmacológico con las derivaciones convencionales no descarta el síndrome de Brugada, y es necesario incluir sistemáticamente las derivaciones precordiales en el segundo y tercer espacios intercostales (AU)