How Do Neural Networks Estimate Optical Flow? A Neuropsychology-Inspired Study.

End-to-end trained convolutional neural networks have led to a breakthrough in optical flow estimation. The most recent advances focus on improving the optical flow estimation by improving the architecture and setting a new benchmark on the publicly available MPI-Sintel dataset. Instead, in this article, we investigate how deep neural networks estimate optical flow. A better understanding of how these networks function is important for (i) assessing their generalization capabilities to unseen inputs, and (ii) suggesting changes to improve their performance. For our investigation, we focus on FlowNetS, as it is the prototype of an encoder-decoder neural network for optical flow estimation. Furthermore, we use a filter identification method that has played a major role in uncovering the motion filters present in animal brains in neuropsychological research. The method shows that the filters in the deepest layer of FlowNetS are sensitive to a variety of motion patterns. Not only do we find translation filters, as demonstrated in animal brains, but thanks to the easier measurements in artificial neural networks, we even unveil dilation, rotation, and occlusion filters. Furthermore, we find similarities in the refinement part of the network and the perceptual filling-in process which occurs in the mammal primary visual cortex.

Unsupervised Learning of a Hierarchical Spiking Neural Network for Optical Flow Estimation: From Events to Global Motion Perception.

The combination of spiking neural networks and event-based vision sensors holds the potential of highly efficient and high-bandwidth optical flow estimation. This paper presents the first hierarchical spiking architecture in which motion (direction and speed) selectivity emerges in an unsupervised fashion from the raw stimuli generated with an event-based camera. A novel adaptive neuron model and stable spike-timing-dependent plasticity formulation are at the core of this neural network governing its spike-based processing and learning, respectively. After convergence, the neural architecture exhibits the main properties of biological visual motion systems, namely feature extraction and local and global motion perception. Convolutional layers with input synapses characterized by single and multiple transmission delays are employed for feature and local motion perception, respectively; while global motion selectivity emerges in a final fully-connected layer. The proposed solution is validated using synthetic and real event sequences. Along with this paper, we provide the cuSNN library, a framework that enables GPU-accelerated simulations of large-scale spiking neural networks. Source code and samples are available at https://github.com/tudelft/cuSNN.

Pacemaker-related endocarditis: clinical features and treatment.

BACKGROUND AND AIM OF THE STUDY: Removal of the entire infected system is the traditionally indicated management of pacemaker lead endocarditis (PLE), based on expert recommendations. Herein is described the present authors' experience with this condition. METHODS: Between 1987 and 2004, all consecutive patients with PLE treated at a tertiary referral university hospital and a community hospital were prospectively selected. Clinical features, management and outcome were analyzed. RESULTS: Thirteen cases of PLE were diagnosed. Surgery was performed in 10 cases, and medical treatment alone in three (due to advanced age in two cases and because of terminal colon cancer in one case). Four subjects died before discharge: three deaths occurred after surgery (one patient died due to refractory ventricular arrhythmia and two from persistent sepsis), and one unoperated patient died from sepsis and severe renal failure. No deaths or late surgeries were observed after a mean follow up period of 37 +/- 14 months. Both patients who survived hospitalization and underwent only medical treatment were free from late complications after 30 and 60 months follow up, respectively. CONCLUSION: Some patients with PLE present a good evolution without surgery, suggesting that surgical treatment is not mandatory in this situation. However, an indication for surgery may be similar to that for other cases of infective endocarditis.

Clinical features and outcome of non-drug-addicted patients with infective endocarditis and perivalvular abscess.

BACKGROUND AND AIM OF THE STUDY: Perivalvular abscess is a serious complication in infective endocarditis (IE) that confers a poor prognosis. Few data are available concerning the long-term outcome of these patients. The study aim was to determine clinical features and long-term prognosis of non-drug addict patients with IE complicated by perivalvular abscess. METHODS: Among a consecutive series of 241 patients with IE, 30 (12.4%) were diagnosed with perivalvular abscess and treated at the authors' institution over a 15-year period. A comparative analysis of patients with perivalvular abscess and other patients in the series was performed. RESULTS: Perivalvular abscess was more frequently associated with aortic valve endocarditis (93% versus 35%, p <0.05), and Streptococcus sp. was the predominant microorganism. Severe complications during hospital admission were more common in patients with perivalvular abscess (100% versus 61%, p <0.01). In-hospital mortality was significantly higher in patients with perivalvular abscess (33% versus 15%, p <0.05). Event-free survival at five years among survivors of the in-hospital phase was 86% in patients with perivalvular abscess, and 83% in those without abscess (p = NS). CONCLUSION: Patients with IE and perivalvular abscess have a higher in-hospital mortality rate, as major complications are more common in these patients. However, among patients who survived the active phase of the disease, long-term survival was similar with or without perivalvular abscess.

Short- and long-term results of a programme for the prevention of readmissions and mortality in patients with heart failure: are effects maintained after stopping the programme?

UNLABELLED: The objective of the study was to evaluate whether improvements obtained during an intervention programme were maintained after the programme was stopped. 153 patients discharged with a diagnosis of heart failure (HF) were randomized to either usual care or an intervention programme, which included patient education, consultation with the cardiologist and monitoring in the Heart Failure Unit. After an average period of 16+/-8 months, the intervention programme was stopped. One year later, all the patients were re-examined to assess HF readmissions, all-cause mortality, quality of life, and prescribed medical treatment. During the 16+/-8-month treatment period, patients in the intervention group had a lower rate of HF readmissions (17% vs. 51%, p<0.01), less all-cause mortality (13% vs. 27%, p=0.03), improvement in quality of life (1.5+/-0.8 vs. 1.9+/-1, p=0.03) and optimisation of medical treatment was achieved. One year after stopping the intervention, there was no difference in HF readmissions (28% vs. 25%, p=0.72), all-cause mortality (14% vs. 17%, p=0.64) and quality of life (1.7+/-0.9 vs. 1.8+/-1, p=0.24) between the groups. Survival and the probability of not being readmitted due to HF were similar in both groups. There was also a reduction in the use of beta-blockers and spironolactone in the intervention group. CONCLUSIONS: The positive effects of an intervention programme are clearly reduced when it is stopped, due to less strict control of the patients and a decrease in the use of drugs with proven efficacy in HF.

Análisis de coste-beneficio de los programas de prevención de reingresos en pacientes hospitalizados por insuficiencia cardíaca. Impacto económico de las nuevas formas de asistencia a la insuficiencia cardíaca / A Cost-Benefit Analysis of Disease Management Programs for Preventing Rehospitalizations in Patients With Heart Failure. Economic Impact of New Organizative Forms of Heart Failure Management

El pronóstico de la insuficiencia cardíaca crónica (ICC)sigue siendo malo, a pesar de los avances recientemente efectuados en su tratamiento. Una de las causas para la escasa mejoría pronostica obtenida es que no se aplican las medidas terapéuticas adecuadas, debido a la enorme magnitud del problema y a la complejidad del tratamiento. Los programas de intervención y educación en pacientes con ICC han demostrado mejorar la calidad del tratamiento y también su pronóstico, al reducir los ingresos y mejorarla supervivencia. Sin embargo, los efectos de estos programas en la relación coste-beneficio y su impacto económico no son bien conocidos. En un trabajo realizado en nuestro centro se incluyó a 153 pacientes consecutivos dados de alta con el diagnóstico de ICC en 1999.Se asignó a los pacientes de forma aleatoria a un grupo de intervención (n = 76) (programa de intervención basado en la información y educación del paciente y los familiares, estrecho seguimiento clínico y la posibilidad de libre consulta telefónica o personal a un cardiólogo de nuestro servicio) o a un grupo control (n = 77) (tratamiento habitual). Tras un seguimiento de 15,8 ± 6 meses se consiguió una reducción significativa de la mortalidad, delos reingresos por ICC y de la estancia media hospitalaria. El número total de días de ingreso por ICC fue de 593en el grupo control y de 114 días en el grupo intervención, con una reducción de 479 días de ingreso en dicho grupo. Dado que el coste de la estancia fue de 421,25euros/día, el coste total evitado fue de 216.148,75 euros en los 15,8 meses, lo que representa un gasto evitado de163.953,4 euros/año. Los gastos del programa suponen2.645,91 euros/mes, por lo que se ahorraron 132.202,48euros/año. En conclusión, la relación coste-beneficio de un programa como el descrito es favorable (AU)

Prognosis of chronic heart failure (CHF) continues to be poor, in spite of recent advances lack in therapy. One of the main reasons for this persistent bad prognosis is the not application of recommended drug therapy, perhaps due, at least in part, to the great prevalence of CHF and the complexity of treatment. Disease management programs have shown to improve therapy and prognosis inpatients with CHF, decreasing hospital admissions and improving survival. Nevertheless, the cost-benefit effect and the economic impact of such programs are not well-known. We performed a prospective trial involving 153consecutive patients diagnosed of heart failure in 1999 in our hospital, and randomized in two groups: the intervention(n=76) and the control group (n=77). The interventional program was based on the information and education of the patient and its surrounding and the possibility of free telephonic or personal consultation with our cardiologist. Patients from the control group received usual care. After 15.8±6 months of follow-up, a significant reduction of mortality, heart failure readmissions and hospital stay were observed in the intervention group. The total number of days of hospital stay was 593 in the control group and 114 days in the intervention group, avoiding 479 days of hospital stay in this group. Given a cost of the hospital stay of 421.25 euros/day, the total cost eluded was 216148.75 euros in 15.8 months, representing savings of 163953.4 euros in one year. The expenses of the program were 2645.91 euros/month, resulting in savings of 132202.48 euros/year. In conclusion, the cost to benefit ratio of our program is favourable (AU)

Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program.

AIMS: Disease management programs can reduce hospitalizations in high-risk heart failure (HF) patients, but generalizability to the population hospitalized for HF remains to be proven. We aimed to assess the effectiveness of a discharge and outpatient management program in a non-selected cohort of patients hospitalized for HF. METHODS AND RESULTS: Patients admitted with decompensated HF were randomized to receive usual care (n=174) or an intervention (n=164) consisting of a comprehensive hospital discharge planning and close follow-up at a HF clinic. After a median of 509 days, there were fewer events (readmission or death) in the intervention as compared with the control group (156 vs. 250), which represents 47% (95%CI: 29-65; P<0.001) event reduction per observation year. At 1-year, time to first event, time to first all-cause and HF readmission, and time to death were increased in the intervention group (P<0.001). All-cause and HF readmission rates per observation year were significantly lower, quality of life improved and overall cost of care was reduced in the intervention group. CONCLUSIONS: This comprehensive hospital discharge and outpatient management program prolonged time to first event, reduced hospital readmissions, improved survival and quality of life of patients hospitalized for HF, while reducing cost of management.

[Short-term results with the ross procedure. Does the etiology of aortic valvulopathy affect the outcome?]. / Resultados a corto plazo en la técnica de Ross. Influye la etiología de la valvulopatía aórtica?

INTRODUCTION: The Ross procedure has become established as an appropriate method for aortic valve replacement in children and young adults. There is controversy regarding the results of this surgical technique depending on whether the aortic valve disorder is congenital or acquired. The objective of this study was to analyze the outcome of this technique in different etiologies. PATIENTS AND METHOD: We analyzed 61 patients who underwent the Ross procedure between November 1997 and November 2001. Age range was 6 to 54 years, and 44 patients (72%) were male. The mean duration of follow-up was 15.6 (10.6) months. The aortic valve lesion was stenosis in 17 patients, regurgitation in 22 and both in 22. The patients were divided into two groups: etiology was congenital in group I (40 patients) and acquired in group II (21 patients: 14 rheumatic, 2 degenerative, 2 endocarditis and 3 other). RESULTS: Pre-intervention data showed significant differences in age, functional class and percentage of patients with previous cardiac surgery. In the last follow-up examination, autograft gradient and homograft gradient were similar in both groups. Diastolic and systolic diameters and left ventricle ejection fraction were normal in both groups and did not differ between groups. Major events during follow-up were: 1 patient died, 1 patient had endocarditis, and 2 patients needed stent implantation in the homograft in group I; 2 patients in group II underwent reoperation because of severe autograft dysfunction. There were no statistically significant differences between groups. CONCLUSION: Short-term morbidity and mortality associated with the Ross procedure are low in patients with either congenital or acquired aortic valvulopathy.

Long-term prognosis of early and late prosthetic valve endocarditis.

A prospective series of 78 cases of prosthetic valve endocarditis (PVE) was studied (35 cases of early PVE and 43 cases of late PVE). The in-hospital mortality rate was significantly higher in patients with early PVE (31% vs 9%, p <0.01) because the onset of heart failure was more common in these patients (55% vs 37%, p <0.05). However, event-free survival at 4 years in survivors to the active phase was not different (74% and 82%, respectively).

[Clinical characteristics and medium-term prognosis of patients with heart failure and preserved systolic function. Do they differ in systolic dysfunction?]. / Características clínicas y pronósticos a medio plazo de la insuficiencia cardíaca con funcón sistólica conservada. ¿Es diferente de la insuficienca cardíaca sistólica?

OBJECTIVES: To assess the prevalence, clinical profile and medium-term prognosis in patients with heart failure and preserved systolic ventricular function compared to those with systolic dysfunction. PATIENTS AND METHOD: 153 patients were included, 62 with preserved systolic ventricular function (left ventricular ejection fraction > or = 45%) and 91 with impaired systolic ventricular function (left ventricular ejection fraction < 45%). The mean follow-up period was 25 10 months. RESULTS: Mean age was similar (66 10 vs. 65 10; p = 0.54). There was a higher proportion of women among patients with preserved systolic function (53% vs. 28%; p < 0.01). Ischemic and idiopathic cardiomyopathy were the most common causes of heart failure in patients with systolic dysfunction, whereas valvular disease and hypertensive cardiopathy were the most common in patients with preserved systolic function. Angiotensin-converting enzyme inhibitors and beta-blockers were more often prescribed in patients with impaired systolic ventricular function (86% vs. 52%; p < 0.01 and 33% vs. 11%; p < 0.01, respectively). There were no differences between the groups in terms of mortality rate (37% vs. 29%), readmission rate for other causes (29% vs. 23%), readmission rate for heart failure (45% vs. 45%), cumulative survival (51% vs. 62%) and the likelihood of not being readmitted for heart failure (50% vs. 52%). In the multivariate analysis, left ventricular ejection fraction was not a predictor of death or readmission because of heart failure. CONCLUSIONS: In a large proportion of patients with heart failure, systolic ventricular function is preserved. Despite the clinical differences between patients with preserved and impaired systolic ventricular function, the medium-term prognosis was similar in both groups.

Características clínicas y pronóstico a medio plazo de la insuficiencia cardíaca con función sistólica conservada. ¿Es diferente de la insuficiencia cardíaca sistólica? / Clinical characteristics and medium-term prognosis of patients with heart failure and preserved systolic function. Do they differ in systolic dysfunction?

Objetivos. Analizar la prevalencia, las características clínicas y el pronóstico a medio plazo de los pacientes con insuficiencia cardíaca y función sistólica conservada, y compararlos con los que presentan disfunción ventricular. Pacientes y método. Se incluyó a un total de 153 pacientes, 62 con función sistólica conservada (fracción de eyección ventricular izquierda 45 por ciento) y 91 con disfunción ventricular (fracción de eyección < 45 por ciento). El seguimiento medio fue de 25 ñ 10 meses. Resultados. Las edades medias fueron similares (66 ñ 10 frente a 65 ñ 10 años; p = 0,54). La proporción de mujeres fue mayor entre los pacientes con función sistólica conservada (53 frente a 28 por ciento; p < 0,01). Las miocardiopatías isquémica e idiopática fueron las causas más prevalentes en pacientes con disfunción sistólica, y las valvulopatías y la cardiopatía hipertensiva, en los que tenían una función sistólica conservada. Los pacientes con función sistólica deprimida recibieron inhibidores de la enzima de conversión de la angiotensina y bloqueadores beta en mayor proporción (86 frente a 52 por ciento; p < 0,01 y 33 frente a 11 por ciento; p < 0,01). Las tasas de mortalidad (37 frente a 29 por ciento), reingresos por insuficiencia cardíaca (45 frente a 45 por ciento) y reingresos por otras causas (29 frente a 23 por ciento) fueron similares entre ambos grupos, y tampoco difirieron la supervivencia actuarial (51 frente a 62 por ciento) ni la probabilidad de no reingresar por insuficiencia cardíaca (50 frente a 52 por ciento). La fracción de eyección ventricular izquierda no fue predictora de mortalidad o reingresos por insuficiencia cardíaca. Conclusiones. Una importante proporción de pacientes con insuficiencia cardíaca presentan una función ventricular sistólica conservada. Aunque las características clínicas de estos pacientes son distintas de las de aquellos con disfunción ventricular sistólica, el pronóstico a medio plazo fue similar (AU)

[Prevalence of patent foramen ovale in young patients with cerebral ischemic accident of unknown origin]. / Prevalencia de foramen oval permeable en pacientes jóvenes con accidente isquémico cerebral de causa desconocida.

INTRODUCTION AND OBJECTIVE: Patent foramen ovale has been associated with stroke in young patients with cryptogenic stroke. The purpose of this study is to examine the prevalence of patent foramen ovale in this group of patients, as well as their anatomical and functional characteristics by contrast echocardiography, trying to determine ictus risk markers in young patients with acute ischemic stroke. PATIENTS AND METHOD: Prospective study of 90 patients under the age of 50 who were hospitalised consecutively due to a clinical presentation suggestive of stroke. No cause was found in 55 out of 90 (group I) and the rest, in which an stroke was finally disregarded, were used as the control group (group II). A transthoracic and transesophageal echocardiography examination with 2 types of contrast agents was performed in all patients to determine the presence of a patent foramen ovale and its anatomical and functional characteristics. RESULTS: Patent foramen ovale was observed more frequently in group I than in group II (43 versus 21%; p < 0.05). Among patients with a patent foramen ovale those with an ischemic stroke showed greater mobility of the oval membrane, more frequent large shunts of contrast in a single frame in the left heart, and more frequent shunts at rest. Transesophageal echocardiography without contrast showed a high sensitivity (90%) and specificity (93%) for detecting anatomically permeable foramen ovale whereas contrast transthoracic echocardiography showed a low sensitivity (13%). There were no differences between the two contrasts used. CONCLUSIONS: Near half of young patients with ischemic stroke of an unknown origin have a patent foramen ovale. A bigger mobility of the membrane of the oval cavity and a large degree of shunt contrast as well as shunt at rest detected by contrast transesophageal echocardiography, seem to identify patent foramen ovale patients with ischemic stroke. In these patients, transthoracic echocardiography has low sensibility for detecting permeability of the foramen ovale.

Prevalencia de foramen oval permeable en pacientes jóvenes con accidente isquémico cerebral de causa desconocida / Prevalence of patent foramen ovale in young patients with cryptogenic stroke

Introducción y objetivos. El foramen oval permeable se ha asociado a infartos cerebrales en pacientes jóvenes con ictus criptogénico. El objetivo de este estudio es determinar la prevalencia en este grupo de pacientes de foramen oval permeable, así como las características anatómicas y funcionales del mismo, mediante ecocardiografía con contraste, tratando de determinar los marcadores de riesgo de ictus en pacientes jóvenes con un foramen oval permeable. Pacientes y método. Estudio prospectivo en 90 pacientes menores de 50 años que ingresaron de forma consecutiva por sospecha clínica de accidente cerebrovascular. En 55 pacientes no se encontró ninguna causa (grupo I) y los restantes, en los que se descartó finalmente un ictus, fueron utilizados como grupo control (grupo II). A todos se les realizó un estudio ecocardiográfico transtorácico y transesofágico con 2 tipos de contrastes, para determinar la presencia de foramen oval y las características anatómicas y funcionales del mismo, comparando ambos grupos. Resultados. En el grupo de estudio existió un mayor número de foramen oval permeable que en el grupo control (43 frente a 21 por ciento; p < 0,05). Comparando a los pacientes con foramen permeable de ambos grupos existieron diferencias significativas en la mayor movilidad de la membrana de la fosa oval, en el mayor número de pacientes con paso amplio de contraste, así como con paso del mismo en situación de respiración basal, en el grupo de pacientes que habían tenido ictus. La ecografía transesofágica sin contraste demostró una alta sensibilidad (90 por ciento) y especificidad (93 por ciento) para detectar "foramen permeable anatómico", mientras que la ecografía transtorácica con contraste demostró una baja sensibilidad para detectarlo (13 por ciento). No hubo diferencias entre los 2 contrastes utilizados. Conclusiones. En casi la mitad de los pacientes jóvenes con ictus de origen desconocido se encuentra un foramen oval permeable. Una mayor movilidad de la membrana de la fosa oval y un paso amplio de contraste y en situación de respiración en reposo han resultado marcadores predictores de isquemia cerebral en estos pacientes. La ecografía transtorácica tiene una baja sensibilidad para detectar permeabilidad del foramen, y no existieron diferencias entre los dos contrastes utilizados (AU)

[Risk factors associated with endocarditis without underlying heart disease]. / Factores de riesgo asociados a endocarditis sin cardiopatía predisponente.

Infective endocarditis (IE) pathogenesis has changed in the last decades and there is an increasing number of patients without predisposing heart condition. The aim of this study is to asses the clinical features of these non-drug addict patients affected with IE without underlying heart disease and to identify the potential risk factors. From 196 cases of IE, 49 (25% of the series) occurred in patients without underlying heart disease. A presumed portal of entry was identified in the majority (26 cases). The most frequent were digestive (6 cases), haemodialysis (6 cases) and central venous catheters (4 cases). Right heart valves were more often affected (29 vs 6%; p < 0.01). The distribution of the causative microorganism showed a higher proportion of Staphylococcus (57 vs 30%). Despite a similar in-hospital complication rate and a similar need of surgery during the active phase, their prognosis is better than in those with underlying heart disease.

Factores de riesgo asociados a endocarditis sin cardiopatía predisponente / Risk factors associated with endocarditis without underlying heart disease

La patogenia de la endocarditis infecciosa (EI) ha cambiado en las últimas décadas, siendo cada vez mayor el número de casos sin cardiopatía predisponente. El objetivo de este trabajo es conocer las características de los pacientes no drogadictos afectados de EI sin cardiopatía predisponente e identificar los posibles factores de riesgo para la infección. De 196 casos de EI, 49 (25 por ciento) ocurrieron en pacientes sin cardiopatía predisponente. Se identificó en la mayoría (26 casos) un factor de riesgo para la infección, predominando las enfermedades digestivas (6 casos), hemodiálisis (6 casos) y catéteres venosos centrales (4 casos). La infección se localizó con mayor frecuencia en las válvulas derechas (29 frente a 6 por ciento; p < 0,01), siendo el microorganismo más frecuente Staphylococcus spp. A pesar de una tasa de complicaciones y de necesidad de cirugía en la fase activa similares, el pronóstico de estos pacientes parece ser mejor que en aquellos con cardiopatía predisponente (AU)

Características clínicas y evolución de la endocarditis infecciosa recurrente en no drogadictos / Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts

Introducción y objetivos. La recurrencia de enfermedad se presenta en una considerable proporción de enfermos con endocarditis infecciosa, pudiendo tratarse de un factor que aumente el número de complicaciones. El objetivo de nuestro trabajo fue evaluar si existen características diferenciales entre los episodios únicos y los repetidos de endocarditis, así como estudiar cuál es la evolución y el pronóstico de la endocarditis recurrente en nuestro medio. Pacientes y método. Revisamos de forma prospectiva nuestra serie de 13 episodios de recurrencia de endocarditis entre un total de 196 casos en pacientes no adictos a drogas por vía intravenosa diagnosticados de endocarditis infecciosa en nuestros centros entre 1987 y 2000. Resultados. No encontramos diferencias significativas entre los pacientes con endocarditis recurrente y aquellos con un primer episodio de enfermedad en cuanto a la edad de presentación, el sexo, la válvula afectada o el germen causal. Sí encontramos una mayor frecuencia de pacientes portadores de prótesis valvular en las endocarditis recurrentes (86 por ciento vs 27 por ciento; p < 0,001). Tampoco encontramos diferencias en cuanto a la incidencia de complicaciones ni en la necesidad de cirugía precoz. La mortalidad global alcanzó un 53 por ciento en los casos de recurrencia, en comparación con el 27 por ciento de los primeros episodios (p < 0,05). Las diferencias no alcanzaban significación estadística si se consideraban por separado la mortalidad precoz y la tardía. Conclusiones. La endocarditis recurrente supone el 7 por ciento de casos de nuestra serie. Sus características son similares a las de los primeros episodios, con excepción de una mayor frecuencia de endocarditis protésica y una mortalidad global mayor (AU)

Guías de práctica clínica de la Sociedad Española de Cardiología en endocarditis / Guidelines of the Spanish Society of Cardiology on endocarditis

La endocarditis infecciosa es una enfermedad que afecta, fundamentalmente, a las válvulas cardíacas, con mal pronóstico y que es originada por gran variedad de microorganismos. La profilaxis es muy importante, pero hay muchos interrogantes sobre su verdadera efectividad y la mejor forma de llevarla a cabo. En este artículo se presentan unas recomendaciones en este sentido. El diagnóstico se basa en hallazgos clínicos, bacteriológicos y ecocardiográficos, fundamentalmente siguiendo los criterios de Duke. Los ecocardiogramas transtorácico y transesofágico tienen no sólo valor diagnóstico, sino que son una buena guía para decidir la actitud terapéutica. El tratamiento antibiótico se basa en los hallazgos del hemocultivo, si bien se presentan pautas no sólo específicas para los diferentes gérmenes hallados, sino también en caso de hemocultivos negativos. Por último se valoran las indicaciones y el momento adecuado de la cirugía (AU)

Insuficiencia cardíaca debida a disfunción ventricular sistólica severa de origen hipertensivo. Evolución clínica y funcional a largo plazo / Congestive heart failure associated with hypertensive severe systolic left ventricular dysfunction. Long-term clinical and functional evolution

Objetivos. El objetivo es evaluar la supervivencia y evolución de la clase funcional y de la función ventricular en pacientes con insuficiencia cardíaca severa secundaria a miocardiopatía dilatada hipertensiva.Métodos. Los criterios de inclusión fueron: ingreso por insuficiencia cardíaca clase III o IV, ventrículo izquierdo dilatado con fracción de eyección < 40 por ciento, historia de hipertensión arterial mal controlada y exclusión de otras etiologías. Se han estudiado 17 pacientes, con una edad media de 64 ñ 7 años, varones el 70 por ciento, seguidos durante un tiempo de 3,3 ñ 1 años (mediana: 3 años).Resultados. La fracción de eyección inicial fue de 30 ñ 5 por ciento (20-40), y estaban en clase III el 35 por ciento y en clase IV el 65 por ciento de los pacientes. Recibieron inhibidores de la enzima conversora de la angiotensina el 100 por ciento, diuréticos el 100 por ciento, betabloqueantes el 53 por ciento y calcioantagonistas el 35 por ciento de los pacientes. La supervivencia fue del 100 por ciento. La fracción de eyección pasó del 30 ñ 5 por ciento inicial al 44 ñ 11 por ciento al año, al 50 ñ 11 por ciento a los 3 años y al 51 ñ 10 por ciento al final del seguimiento (p < 0,001). Esta mejoría se consiguió por una reducción del diámetro sistólico ventricular izquierdo (de 51 ñ 4 a 42 ñ 11 mm; p < 0,01), sin cambios en el diámetro diastólico (63 ñ 4 a 59 ñ 11 mm).Conclusiones. La evolución de la disfunción ventricular severa hipertensiva es favorable a largo plazo con un correcto tratamiento (mortalidad nula, mejoría funcional y de la fracción de eyección). Sin embargo, la persistencia de dilatación ventricular indica que el daño miocárdico causado por la sobrecarga crónica de presión no desaparece (AU)

Sustitución valvular aórtica con autoinjerto pulmonar (operación de Ross) en pacientes adultos y pediátricos / Aortic valve replacement with pulmonary autograft (the ross procedure) in adult and pediatric patients

La sustitución valvular aórtica con autoinjerto pulmonar fue descrito por Donald Ross en 1967, aunque no fue ampliamente aceptado por cardiológos y cirujanos cardíacos, fundamentalmente por tratarse de un procedimiento quirúrgico complejo y poner en riesgo dos válvulas cardíacas. En los últimos 10-15 años, los resultados publicados de numerosas series demuestran que se trata de uno de los mejores métodos de reemplazamiento de la válvula aórtica, muy especialmente en pacientes pediátricos y adultos jóvenes.En el presente trabajo, revisamos las indicaciones y contraindicaciones actuales, así como nuestra experiencia clínica con 26 pacientes (adultos y pediátricos) y el análisis de los primeros 22, con un seguimiento mínimo de 6 meses (180-620 días). El seguimiento fue completo (100%). Cinco pacientes eran menores de 14 años. La edad media del grupo fue de 31,4 ± 12,6 años. En 3 pacientes (11%) se había realizado un procedimiento percutáneo previo y otros 4 pacientes (14%) habían sido intervenidos quirúrgicamente. No ha habido ningún caso de mortalidad precoz ni tardía.En el último seguimiento, 19 de estos 22 pacientes (86,36%) no tenían insuficiencia (>= grado 1) del autoinjerto y en un caso ésta era moderada (grado 2). Los 2 pacientes restantes desarrollaron una insuficiencia severa (grado 4) y hubieron de ser reintervenidos, evolucionando de forma satisfactoria. El gradiente pico medio era de 7,85 ± 5 mmHg (3-29) a los 18 meses. Los pacientes con estenosis aórtica preoperatoria mostraron una reducción significativa del índice de masa miocárdica (208,7 ± 32 a 95,8 ± 28,8 g/m2). En estos pacientes, el grosor del septo y de la pared posterior se redujo significativamente, ya en el primer mes.Dos pacientes pediátricos desarrollaron un gradiente transpulmonar > 50 mmHg, implantándose un stent intravascular en uno de ellos. No se ha observado insuficiencia significativa del homoinjerto en ningún caso.Todos los pacientes continúan asintomáticos (grado funcional I) sin medicación. No se ha observado ningún episodio tromboembólico o hemorrágico ni ningún caso de endocarditis. Ningún paciente recibe tratamiento anticoagulante.El seguimiento clínico y ecocardiográfico a medio plazo de nuestra serie demuestra un buen comportamiento, tanto del autoinjerto pulmonar como del homoinjerto, tras el procedimiento de Ross (AU)

Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innmumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180- 620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 ± 12.6 years. Five patients were pediatrics (≤ 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (≥ grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 ± 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 ± 32 a 95.8 ± 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significanthy, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our serie, are excellent after the Ross procedure (AU)