[Beta-blockers in cardiac insufficiency: should they always be considered in the therapeutic strategy? Arguments against]. / Betabloqueantes en la insuficiencia cardíaca: deben incluirse siempre en la estrategia terapéutica? Argumentos en contra.

The evidence supporting the use of beta-adrenergic blockers in the treatment of heart failure secondary to systolic dysfunction is reviewed. Up to date, seven controlled trials of carvedilol in patients with heart failure have been published. It has been concluded that the use of the non-selective, third generation beta-adrenergic blockers, with alpha-adrenergic (vasodilator) and antioxidant properties, carvedilol, is only justified in patients with mild or moderate heart failure without contraindications to beta-adrenergic blockers. There are not data to support the use of carvedilol in patients with severe or unstable heart failure. It seems logical to wait for the results of the ongoing trials (BEST Trial, CIBIS II Trial, COMET Trial, and MERIT Trial) to more precisely define the role that beta-adrenergic blockers should play in the treatment of patients with heart failure. The information presently available suggests that carvedilol should be considered a therapeutic agent for the prevention of progressive clinical heart failure rather than for the treatment of refractory heart failure.

[Surgical treatment of atrial fibrillation]. / Tratamiento quirúrgico de la fibrilación auricular.

Atrial fibrillation is the most frequently found sustained arrhythmia. It increases the risk of thromboembolism and adversely affects cardiac performance because of loss of atrial kick. New surgical treatments of atrial fibrillation have been developed to ablate the origin of abnormal impulses on the atrium. The left atrial isolation and the corridor operation restores the regular rhythm, but do not reduce the risk of thromboembolism because the left atrium may continue to fibrillate. The maze operation has proven to be effective in both converting to sinus rhythm and regaining atrial contractility. However, this method is meticulous and time-consuming and takes more cardiac ischemic time, especially when other cardiac procedures are performed simultaneously.

[Maze technique for the treatment of auricular fibrillation: initial experience]. / Técnica de MAZE para el tratamiento de la fibrilacion auricular: experiencia inicial.

INTRODUCTION AND OBJECTIVES: The MAZE procedure was developed as a surgical approach to the management of patients with atrial fibrillation refractory to medical treatment. This study seeks to identify the risk and benefits of adding the MAZE procedure in patients with atrial fibrillation undergoing surgery for underlying organic cardiac disorders. MATERIAL AND METHODS: Since november 1993, we have performed 10 interventions with the MAZE procedure, for the treatment of refractory atrial fibrillation. The indication to perform the technique was systemic embolism in 5 patients, contraindication for the anticoagulant treatment in two cases and no response to antiarrhythmic treatment in 5 cases. Two patients had more than one indication. In all the cases another surgical procedure was performed, 5 replacements of mitral valve, a mitral repair, one tricuspid repair and tree repairs of an atrial septal defect. RESULTS: Soon after surgery 9 patients were in sinus rhythm, and one in atrial fibrillation. Four patients needed atrial pacing during the first days. One patient required a pacemaker due to symptomatic sinus bradycardia. During the first 3 months, 4 patients had episodes of paroxysmal atrial fibrillation and flutter. One patient died suddenly one month after surgery. Seven patients have completed two years of follow-up, and are in stable sinus rhythm, in functional class I and free of antiarrhythmic drugs. All of them have echocardiographic evidence of mechanical activity in both atria. Left atrium had been reduced from 5.3 +/- 0.7 cm to 4.5 +/- 0.7 cm (p < 0.05). No patient has presented new embolic events. CONCLUSIONS: The MAZE procedure is a good choice in selected patients with atrial fibrillation refractory to medical treatment, or a precedent of systemic embolism. However, several problems can complicate the patient's course.

[Mycotic anuerysm secondary to bacterial endocarditis. Review apropos of a case]. / Anuerisma micótico secundario a endocarditis bacteriana. Revisión a propósito de un caso.

A case is presented of Subacute Bacterial Endocarditis on a biological Duramater Prosthesis. In the evolution curse, the patient presented an intraparenchimal cerebral haemorrhage, where--upon the angiographic studies demonstrated the existence of a mycotic aneurysm in the left median cerebral arterial territory. With specific antibiotic therapy and replacement of the prosthesis, the clinical evolution of the case, was positive, and later angiographies evidenced the disappearance of the aneurysm. The incidence of intracranial mycotic aneurysm complicating bacterial endocarditis is relatively high (up to 4% in post-mortem series). There have been very few cases communicated up to now with angiographic demonstration. Mortality is similar in patients under surgical or medical treatment. The aetipothogenic aspects are discussed, as well as the recommended therapeutic measures.

Late displacement of a ventricular pacing lead after respiratory therapy.

This article presents a case of displacement of the ventricular electrode of a DDD pacemaker occurring 3 years after implantation following a session of respiratory therapy. The incident provoked the loss of the ventricular pacing and left pectoral stimulation. The different techniques for achieving airway patency that can be used in respiratory therapy of patients with permanent pacemakers are discussed.

VDD pacing with single lead in a heart transplant recipient: case report.

Permanent pacemaker implantation is required in a large number of transplantation patients principally because of sinus node dysfunction of the donor atrium. The most suitable mode of pacing in these cases is still subject to controversy. We describe one case of a single lead system of VDD stimulation and sensing of the recipient atrial signal in a 32-year-old patient with posttransplant symptomatic sinus node dysfunction. Physiological adaptation of rate was achieved with recovery of normal receptor sinus node function.