Daño hepático crónico como manifestación de pericarditis constrictiva: reporte de un caso / Chronic liver failure as a manifestation of constrictive pericarditis: report of a case

Constrictive pericarditis (CP) is an uncommon condition which clinical presentation becomes very unspecific, making its diagnosis a hard challenge. It has multiple and varied causes, all of them determine pericardium inflammation and progressive fibrosis that restricts heart filling and develops diastolic dysfunction, expressing mainly as right heart failure. Symptoms of this last condition allow posing different diagnosis as they can appear in many other diseases, including chronic liver disease as happens in the following clinical case. A 27 year-old male patient with a history of progressive edema on his extremities, increased abdominal volume, a 3-month body weight loss, and dyspnea; is firstly diagnosed as CLD after medical Evaluation. However, etiological studies for CLD appear negative and the patient does not respond to general approaches, motivating his hospitalization for further studies. Cardiologic tests reveal pulmonary hypertension, which is studied by MRI showing a thickened pericardium suggesting constriction that is confirmed by cardiac catheterization. The patient undergoes surgery without incidents and a favorable post-operatory period, being completely asymptomatic 3 months later. This clinical case reflects how difficult can become diagnosing CP; as well as presenting the right way to study these patients in order to confirm this alternative diagnosis, the treatment of choice, and the excellent results that surgery can achieve. Finally, CP is a rare condition that must be included within differential diagnosis of patients with clinical manifestations of RHF.

Manejo y fibrilación auricular en el postoperatorio de cirugía cardiaca / Management and evolution of atrial fibrillation in the postoperative cardiac surgery

Introduction: postoperative atrial fibrillation (POAF) is the most frequent arrhythmia in patients that undergo a cardiac surgery. POAF’s prevalence ranges from 10 to 65 percent. Most initial episodes of POAF occurred within the first few days alter cardiac surgery. The prevention of POAF is well known but there are no guidelines and no randomized clinical trial that have evaluated the acute management of the arrhythmia. The aim of this restrospective study was to know themanagement and intrahospital evolution of patients with POAF in our institution. Main results: among 426 patients undergoing a cardiac surgery, the incidence of POAF was 10 percent. We analyzed only 27 patients of the 42 with POAF. Five patients spontaneously restored sinus rhythm (SR) and in the others, the first approach to the management was with betablockers in 15 patients (70 percent). To restore SR, the treatment of choice was pharmacological, only with amiodarone, with 70 percent of conversion to SR. Only three patients needed direct current cardioversion to restore SR. At discharge 5 patients were in AF. Conclusion: the management and evolution of patients with POAF in our institution is similar than reported experiences. The initial treatment is to achieve rate control mainly with betablockers. To restore SR the drug of choice is amiodarone with an efficacy of 70 percent. In the minority of our patients direct current cardioversion was necessary to recover SR. Nearly 19 percent of POAF patients were discharged on AF and 44 percent with antiarrhythmic drugs.

Fibrilación auricular en el postoperatorio de cirugía cardiaca: factores de riesgo y morbimortalidad / Postoperative atrial fibrillation of cardiac surgery: risk factors and morbid-mortality

Introduction: postoperative atrial fibrillation (POAF) is the most frequent arrhythmia observed in patients undergoing a cardiac surgery. The worldwide incidence is 30 to 65 percent of cardiac surgery procedures, and is more frequent in patients undergoing a cardiac valve surgery. This arrhyhtmia implies an increment in the lenght and in the total costs of hospitalization, and is associated with serious adverse events like stroke, bleeding and death. The aim of this study was to know the incidence, risk factors, morbidity and mortality associated with POAF in our institution during one year. Main results: we analyze 321 patients that undergone a cardiac surgery during 2003. The incidence of POAF was 6,7 percent and the risk factors associated were the use of cold crystalloid cardioplegia (p < 0,05) and dyslipidemia (p < 0,05). Also, the left ventricle end diastolic diameter was larger but not significant (p = 0,053) in patients with POAF in comparison with patients without POAF. POAF results in an increment of the costs and the lenght of hospitalization. There was no mortality attributed to this arrhythmia in our patients. Conclusion: in this retrospective analysis of patients undergoing cardiac surgery there was a lower incidence of POAF in comparison with other series. The risk factors in this population of patients were the use of cold crystalloid cardioplegia and dyslipidemia. Although this arrhythmiawas associated with more days of hospitalization, there were no difference in mortality between patients with POAF and patients without POAF.

Avances en la prevención de eventos tromboembólicos en pacientes con fibrilación auricular / Update on the prevention of thromboembolic phenomena in atrial fibrillation

Atrial fibrillation is the most common sustained arrhythmia in clinical practice and is associated to thromboembolic complications. Anticoagulation with vitamin K antagonists is clearly useful to reduce the incidence of emboli, but associated with important limitations. Therefore, there is an active search for medications that are more effective and simpler to prescribe and manage. Synthetic pentasaccharides of heparin such as idraparinux for parenteral use, showed promising results. Direct inhibitors of thrombin were also useful for the prevention of thromboembolism. However, they were withdrawn from the market due to potentially fatal adverse reactions. Other area of investigation has been the effectiveness of the combination of antiplatelet agents such as aspirin and clopidrogel. Although this combination is attractive, results of clinical trials must be awaited to have an opinion about its real usefulness. Finally, ieft atrial appendage transcatheter occlusion (PLAATO) is an effective and reasonably safe method for patients with contraindications for anticoagulation or those that continue to embolize despite well prescribed anticoagulation. The long term results of this intervention must also be awaited.

Infecciones oportunistas por hafnia alvei: descripción de tres casos y revisión de la literatura / Opportunistic infections caused by hafnia alvei: report of 3 cases and review of literature

Las infecciones por Hafnia alvei son muy infrecuentes en la práctica clínica y se presentan primordialmente como infecciones oportunistas. Describimos tres pacientes con infecciones asociadas a aislamiento de H. alvei en diferentes sitios anatómicos. En dos casos H. alvei se recuperó de hemocultivos en pacientes afectados por un nódulo pulmonar inflamatorio inespecífico y cáncer de páncreas respectivamente. En un tercer caso este agente se aisló de secreción traqueal en un paciente ingresado por un traumatismo complicado de cráneo. Los casos se asociaron a sepsis o fiebre y la trascendencia clínica de H. alvei fue evidente en sólo uno con bacteremia, con recuperación tras terapia antimicrobiana. La respuesta terapéutica fue incierta cuando H. alvei se recuperó del tracto respiratorio en un paciente o incluso no fue necesaria en una bacteremia autolimitada que afectó a un paciente con cáncer de páncreas. La sensibilidad antimicrobiana fue variable, en un caso enteramente sensible y en otro completamente resistente. Se adjunta revisión de la literatura