Perfusión de furosemida subcutánea como tratamiento paliativo en insuficiencia cardiaca refractaria / Subcutaneous furosemide infusion as palliative treatment in refractory end-stage heart failure

Resumen En la insuficiencia cardiaca terminal los síntomas predominantes habitualmente están relacionados con la congestión; sin embargo, la resistencia a diuréticos vía oral es frecuente y necesita tratamiento parenteral para paliar los síntomas. La administración intravenosa de furosemida requiere hospitalización o asistencia hospitalaria, lo que supone un deterioro significativo de la calidad de vida de pacientes en fases avanzadas de la enfermedad. La administración subcutánea continua de furosemida mediante infusor elastomérico es una técnica eficaz con baja tasa de complicaciones graves que permite la administración de diurético parenteral en el ámbito domiciliario, y evita la necesidad de hospitalizar. A pesar de que esta modalidad de tratamiento no está aceptada en ficha técnica y requiere más estudios que precisen su indicación, puede suponer un recurso adecuado para pacientes seleccionados. Se presenta el caso de una paciente con insuficiencia cardiaca avanzada, síntomas congestivos y ausencia de respuesta a tratamiento deplectivo vía oral, tratada con perfusión continua subcutánea domiciliaria de furosemida mediante infusor elastomérico de forma prolongada.

Abstract In end-stage heart failure the predominant symptoms are usually associated with congestion. However, the resistance to oral diuretics is common and requires parenteral treatment to alleviate the symptoms. The intravenous administration of furosemide requires hospital admission or hospital care. This leads to a significant decrease in the quality of life of patients in advance stages of the disease. The continuous subcutaneous infusion of furosemide using an elastomeric pump is an effective technique, with a low rate of serious complications that allows a parenteral diuretic to be administered in the home environment and thus avoiding the need for hospital admission. Despite this mode of treatment not being indicated in the drug data sheet, and requires more studies that specify its indication, it may be a suitable recourse for selected patients. It is presented a case of a patient with advanced heart failure, congestive symptoms, and a lack of response to oral diuretics treatment, and then treated with a continuous and prolonged subcutaneous infusion of furosemide at home using an elastomeric infusion pump.

Segunda publicación nuevos anticoagulantes orales: guía práctica para los médicos / Second publication new oral anticoagulants: a practical guide for doctors

Resumen Los nuevos anticoagulantes orales suponen una atractiva alternativa para los clásicos antagonistas de la vitamina K (AVKs) en la prevención de ictus en pacientes con fibrilación auricular no valvular. A diferencia de los AVKs, estos anticoagulantes no requieren monitorización ni ajuste de dosis y poseen propiedades farmacológicas favorables. La falta de antídoto efi caz, su coste, o dudas en cuanto a la seguridad en los pacientes con enfermedad renal avanzada pueden explicar su lento ritmo de expansión. El uso seguro y eficaz de estos nuevos medicamentos depende en gran medida de la experiencia clínica entre la comunidad médica. Esta revisión discute las peculiaridades de los nuevos anticoagulantes orales, propor cionando algoritmos prácticos y fáciles de usar para su aplicación en la práctica clínica diaria.

Abstract New oral anticoagulants suppose an attractive alternative for classical vitamin K antagonists (AVKs) in stroke prevention for patients with non-valvular atrial fibrillation. Unlike AVKs, these anticoagulants do not require monitoring or dose adjustment and have favourable pharmacological properties. The lack of an effective antidote, its cost, or doubts regarding the safety of patients with advanced kidney disease may explain its slow rate of expansion. The safe and effective use of these new medications depends largely on clinical experience among the medical community. This review discusses the peculiarities of the new oral anticoagulants, providing practical and easy-to-use algorithms for their application in daily clinical practice.

Recomendações para Avaliação por Imagens das Próteses Valvares Cardíacas / Recommendations for the Imaging Assessment of Prosthetic Heart Valves

Disfunção de prótese valvar cardíaca (PVC) é rara, porém é uma potencial ameaça à vida. Estabelecer o exato mecanismo da disfunção da PVC é desafiador, no entanto é essencial para determinar a estratégia terapêutica apropriada. Na prática clinica, uma abordagem abrangente que integra vários parâmetros de morfologia e função avaliados pelo eco transtorácico 2D/3D e transesofágico são fundamentais para detectar e quantificar a disfunção da PVC. A cinefluoroscopia, a tomografia computadorizada com multidectetores, a ressonância magnética cardíaca, e em menor escala, a imagem nuclear, são ferramentas complementares para o diagnóstico e abordagem das complicações das PVC. Este documento apresenta recomendações para o uso de imagem em multimodalidade para avaliação das PVCs

Factores asociados a aumento de la sensibilidad del ecocardiograma transtorácico en el diagnóstico de la endocarditis infecciosa / Associated factors to increased sensitivity in the transthoracic echocardiogram for the diagnosis of infective endocarditis

INTRODUCTION AND OBJECTIVES: Echocardiography is considered a basic tool in the diagnosis and management of infective endocarditis. Transesophageal echocardiography is more sensitive than transthoracic echocardiography. Our aim was to describe which factors are related to the ability of transthoracic echocardiography to establish the diagnosis of infective endocarditis. The presence of this factors in a patient with a normal transthoracic echocardiography would make unnecessary to perform a transesophageal echocardiography and would suggest to seek for other diagnostic possibilities. METHODS: 127 consecutive patients admitted to our hospital with the diagnosis of infective endocarditis and a complete transthoracic echocardiography and transesophageal echocardiography comprised our study group. Predisposing factors and clinical, echocardiographic and microbiological variables were studied. RESULTS: The presence of a cardiac murmur, the presence of an optimal acoustic window, degenerative valvular disease as the predisposing factor for infective endocarditis and positive blood cultures were related to the ability of transthoracic echocardiography to diagnose the existence of signs of infective endocarditis on its own. Nevertheless, only the presence of a cardiac murmur (RR 2.724; 95% CI 1.071-6.926; p 0,035) and the presence of an optimal acoustic window (RR 5.538; 95% IC 2.75-11.15; p < 0.001) were found as independent factors to detect those patients in which transthoracic echocardiography is able to diagnose signs of infective endocarditis on its own. CONCLUSIONS: The diagnostic accuracy of transthoracic echocardiography to detect echocardiographic signs of infective endocarditis is high in those patients with cardiac murmur and optimal acoustic window. In those patients with these characteristics, without prosthetic heart valves and a negative transthoracic echocardiography for infective endocarditis other diagnostic possibilities should be ruled out before performing of a transesophageal echocardiography.

Utilidad de la ecocardiografía tridimensional en tiempo real en la valoración de la estenosis mitral reumática / Usefulness of Real Time 3D echocardiography in assessment of rheumatic mitral stenosis

Hasta el momento, la valoración de la severidad de la estenosis miral reumática ha estado basado en métodos Doppler, muy influenciares por las condiciones hemodinámicas del paciente y en métodos de planimetría valvular obtenida a partir de imágenes bidimensionales. La ecocardiografia 3D en tiempo real ha hecho su aparición en la rutina clínica diaria, proporcionando imágenes de alta calidad en tres dimensiones y requiriendo un muy corto período de tiempo para su adquisición. En el presente trabajo tratamos de realizar una puesta al día de la utilidad de esta técnica en la valoración de la severidad de la estenosis mitral reumática. Estos hallazgos están basados en la experiencia de nuestra Unidad de Imagen Cardiovascular del Hospital Clínico San Carlos de Madrid.

To date, the assessment of rheumatic mitral stenosis has been based on Doppler methods, which have a high dependence on the hemodinamic conditions and on the planimetry obtained from 2D echo images. Real Time 3D echocardiography has been implemented in the daily clinical practice. It provides high quality 3D images and the acquisition time is very short. In the present work, we try to show the "state of the art" of Real Time 3D echocardiography in the assessment of rheumatic mitral stenosis. These findings are based on the experience of our "Unidad de Imagen Cardiovascular" at the Hospital Clínico San Carlos de Madrid. (Arch Cardiol Mex 2005; 75:210-221).