Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry.

INTRODUCTION: There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. METHOD: A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. RESULTS: In the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28-5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38-5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. CONCLUSIONS: The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

Análisis de la atención al infarto con elevación del segmento ST en España. Resultados del Registro de Código Infarto de la ACI-SEC / Analysis of the management of ST-segment elevation myocardial infarction in Spain. Results from the ACI-SEC Infarction Code Registry

Introducción y objetivos Las redes de Código Infarto deben garantizar una atención al infarto agudo de miocardio con elevación del segmento ST con buenos resultados clínicos y dentro de los parámetros de tiempo recomendados. No hay información contemporánea sobre el funcionamiento de estas redes en España. El objetivo es analizar las características clínicas de los pacientes atendidos, el tiempo hasta la reperfusión, las características de la intervención realizada y la mortalidad a 30 días. Métodos Registro prospectivo, observacional y multicéntrico de pacientes los consecutivos atendidos en 17 redes de Código Infarto en España (83 centros con Código Infarto) entre el 1 de abril y el 30 de junio de 2019. Resultados Se atendió a 5.401 pacientes (media de edad, 64±13 años; el 76,9% varones), de los que 4.366 (80,8%) sufrieron un infarto con elevación del ST. De estos, se trató al 87,5% con angioplastia primaria, al 4,4% con fibrinolisis y al 8,1% sin reperfusión. En los casos tratados con angioplastia primaria, el tiempo entre el inicio de los síntomas y la reperfusión fue 193 [135-315] min y el tiempo entre el primer contacto médico y la reperfusión, 107 [80-146] min. La mortalidad total a 30 días por infarto agudo de miocardio con elevación del ST fue del 7,9%, mientras que entre los pacientes tratados con angioplastia primaria fue del 6,8%. Conclusiones Se trató con angioplastia primaria a la inmensa mayoría de los pacientes con infarto agudo de miocardio con elevación del ST, y en más de la mitad de los casos el tiempo desde el primer contacto médico hasta la reperfusión fue <120 min. La mortalidad a 30 días fue relativamente baja (AU)

Introduction and objectives ST-segment elevation myocardial infarction (STEMI) networks should guarantee STEMI care with good clinical results and within the recommended time parameters. There is no contemporary information on the performance of these networks in Spain. The objective of this study was to analyze the clinical characteristics of patients, times to reperfusion, characteristics of the intervention performed, and 30-day mortality. Methods Prospective, observational, multicenter registry of consecutive patients treated in 17 STEMI networks in Spain (83 centers with the Infarction Code), between April 1 and June 30, 2019. Results A total of 5401 patients were attended (mean age, 64±13 years; 76.9% male), of which 4366 (80.8%) had confirmed STEMI. Of these, 87.5% were treated with primary angioplasty, 4.4% with fibrinolysis, and 8.1% did not receive reperfusion. In patients treated with primary angioplasty, the time between symptom onset and reperfusion was 193 [135-315] minutes and the time between first medical contact and reperfusion was 107 [80-146] minutes. Overall 30-day mortality due to STEMI was 7.9%, while mortality in patients treated with primary angioplasty was 6.8%. Conclusions Most patients with STEMI were treated with primary angioplasty. In more than half of the patients, the time from first medical contact to reperfusion was <120 minutes. Mortality at 30 days was relatively low (AU)

[Cardiac pathology of extracardiac origin (IX)> Cardiac pathology in the patient with chronic nephropathy]. / Patología del corazón de origen extracardíaco (IX). Patología cardíaca en el paciente con nefropatía crónica.

Cardiac disease constitutes a common complication among patients with renal failure. This is partly due to the high incidence of shared risk factors, such as hypertension or diabetes mellitus, and some to specific factors inherent in renal disease. It implies a high incidence of cardiac failure and ischemic heart disease (frequently without significant coronary artery obstructions) with important associated morbidity and mortality. Pericardial disease, valvular involvement and arrhythmia are also common among these patients. The management of these complications in patients with endstage renal disease has some particularities, specially in the field of drug therapy.

[Bradycardia and asystolia secondary to epileptic crisis. Report of a case]. / Bradicardia y asistolia secundarias a crisis epiléptica. A propósito de un caso.

We report the case of a 21 year old man with bradycardia and asystolia after a seizure. No cardiac disease could be demonstrated, but electroencephalography after sleep deprivation showed the presence of a temporal irritative focus. The importance of differential diagnosis between cardiogenic syncope and loss of consciousness due to epilepsy is discussed.

[Wiktor stent in de novo lesions: immediate results in 100 consecutive patients]. / Stent de Wiktor en lesiones de novo: resultados inmediatos en 100 pacientes consecutivos.

BACKGROUND: Randomized trials which compare different stents are lacking and the studies to test the behavior of the Wiktor stent in de novo lesions have not been substantiated by large numbers and with consistent results. METHODS: The lesions were predilated with a conventional balloon 1/2 mm smaller in diameter than the stent to be used. The overdilation was done with the same balloon in which the stent comes mounted. The quantitative coronary analysis was "off line" by the automatic edge detection method with the CMS system by Medis. The post implantation treatment was aspirin and ticlopidine in most of the patients and they were discharged 24-48 hours after the procedure. RESULTS: In one hundred consecutive patients 112 Wiktor stents were attempted to treat 106 de novo lesions. All stents but one were successfully implanted. The quantitative coronary analysis of the treated lesions showed a pre-procedure minimal luminal diameter of 0.85 +/- 0.65 mm for a reference diameter of 3.18 +/- 0.49 mm. The minimal luminal diameter after stent implantation was 2.97 +/- 0.39 mm for a reference diameter of 3.42 +/- 0.46 mm. The diameter stenosis changed from 73 +/- 18% pre-procedure to 13 +/- 9% after stent implantation. One patient was sent to emergency surgery. Another patient was referred for a semiselective bypass surgery. There was no mortality. One patient suffered a non Q wave myocardial infarction. There were no important bleeding complications. There were no cases of subacute thrombosis. All the patients were contacted by telephone one month after the procedure. CONCLUSIONS: In this study we have demonstrated that Wiktor stent implantation is associated with excellent immediate results. The new model makes stent implantation a rapid, safe and relatively easy procedure. If the angiographic result is good, there is no need for an stringent anticoagulation regimen. We have to wait for long term clinical and angiographic results to determine the role of Wiktor stent in novo lesions.

[Coronary endoprosthesis (stents) implanted without coumadin administration: one year's experience]. / Implantación de endoprótesis coronarias (stents) sin dicumarínicos: un año de experiencia.

BACKGROUND AND OBJECTIVES: Subacute occlusion and bleeding complications have been the major limitations of coronary stenting. Several authors have suggested the nonessential role of oral anticoagulation to prevent occlusions. METHODS: We treated 121 patients (125 stent procedures with initial angiographic success) with the following regimen: heparin 10-20,000 IU i.v. and ASA 325 mg i.v. during the procedure, followed by ASA 125-325 mg/day/6 months and ticlopidine 250-500 mg/day/3 months. 40 patients were also treated with enoxaparine (14,000 IU/day, median) for 10 days. RESULTS: 172 stents (119 Palmaz-Schatz, 35 Wiktor and 18 of other types) were implanted in 148 lesions (in 45 cases with non-occlusive dissection or suboptimal results and the rest electively). Most of the stents were deployed at high pressure (median 14 atm.). The procedure was ended when the stent expansion was considered as optimal by angiography and/or intravascular ultrasound. No patient developed signs of subacute occlusion at follow-up (30-441 days). 2 patients developed non-Q wave myocardial infarction (occlusion of side branches). The rates of bleeding and vascular complications were 0.8% and 1.6%, respectively. CONCLUSIONS: Coronary stenting with high pressure dilatation and without subsequent anticoagulation seems to be associated with low rates of subacute occlusion and bleeding or vascular complications.

[The usefulness of transesophageal echocardiography in general intensive care units]. / Utilidad de la ecocardiografía transesofágica en las unidades de cuidados intensivos generales.

BACKGROUND AND OBJECTIVES: It's well known the utility of transesophageal echocardiography in the evaluation of cardiological patients that are critically ill. However, there is less experience about this usefulness in non-cardiological critically ill patients. METHODS: To assess the utility and safety of the method we analyzed 51 correlative studies of patients admitted to our general Intensive Care Unit. Forty-seven patients (92%) were on mechanical ventilation and in 24 patients (47%) continuous assessment of the hemodynamic variables were available. RESULTS: The most frequent diagnoses on admission were sepsis (23.5%) and shock status (17.6%). The indications were: suspicion of endocarditis (15 patients), hemodynamic instability (11 cases), cardiac source of embolus (10), suspicion of cardiac tamponade (4), suspicion of aortic dissection (4) and other causes in 7. The study confirmed the clinical suspicion in 31 cases (60.8%), excluded it in 15 (29.4%) and established a new, non-suspected, diagnosis in 5 patients (9.8%). There were major diagnostic changes in 16 patients (31.6%) and minor changes in 17 (33.3%) comparing the results of the transesophageal and transthoracic approaches. It was also assessed the influence of the result on the clinical management of the patient: in 32 cases (62.8%) there were a significant change in the treatment; in 5 patients (9.8%) cardiac surgery was prompted by echocardiography. Only in 3 patients hypertensive reactions and tachycardia were detected, without posterior consequences. CONCLUSIONS: Transesophageal echocardiography can be safely performed and has a definite role in the diagnosis (showing sometimes non-suspected abnormalities) and management of non-cardiological critically ill patients.

[The accuracy and applicability of different methods in the Doppler technic for the quantification of mitral stenosis]. / Precisión y aplicabilidad de los diversos métodos en técnica Doppler para la cuantificación de la estenosis mitral.

INTRODUCTION AND OBJECTIVES: We analyse the applicability and accuracy of the various Doppler methods for quantification of mitral stenosis as well as the value of combining measurements. PATIENTS AND METHODS: The study comprised 74 patients with reliable planimetry of mitral orifice. The following Doppler methods were tested: a) pressure half-time; b) color jet width at the mitral valve orifice in the apical long-axis view (short diameter) and its width in the 90 degree rotated view (long diameter), assuming an elliptic mitral orifice; c) proximal isovelocity surface area from the 4-chamber view assuming a hemispheric surface, and d) the continuity equation. The mean value of mitral valve area estimates from all applicable Doppler methods was calculated in each patient. RESULTS: The rates of applicability of each method were, respectively: 85, 97, 97 and 53% (p < 0.01). The correlations--r (SEE)--between each method and planimetry were: 0.86 (0.17 cm2), 0.81 (0.19 cm2), 0.74 (0.21 cm2) and 0.83 (0.18 cm2), respectively. The highest correlation was found with the mean value (r = 0.90; SEE = 0.14 cm2), and only this parameter was selected by stepwise multiple regression analysis (r = 0.93; SEE = 0.12 cm2). CONCLUSIONS: The continuity equation method has the lowest level of obtainable results owing to the high incidence of mitral regurgitation. The mean value of mitral area estimates from all applicable methods in each patient showed the closest correlation with planimetry, thus the performance of these Doppler methods provides improved accuracy in the quantification of mitral stenosis.

Emergency coronary stenting for acute occlusive dissection of the left main coronary artery.

Catheter-induced left main coronary artery dissection is a rare but serious complication of diagnostic cardiac angiography. We report the case of a patient with mitral regurgitation and accidental dissection of the left main coronary artery successfully managed with intracoronary stent that allowed emergent surgical revascularization and mitral replacement.