Infección por trypanosoma cruzi y bloqueo cardíaco del nodo auriculoventricular en el salvador / Trypanosoma cruzi infection and atrioventricular-nodal heart block in El Salvador

Resumen La enfermedad de Chagas es endémica en América Latina y sigue siendo un problema regional a pesar de que su frecuencia ha disminuido gracias a importantes avances en salud ambiental. Para determinar su frecuencia en pacientes con enfermedades miocárdicas de El Salvador, se llevó a cabo una in vestigación observacional retrospectiva en nuestro hospital que es un centro de referencia de nivel nacional. Se revisó el registro del Laboratorio de Chagas en el período 2013-2015 para conocer cuántos individuos internados en la Unidad Cardiológica eran positivos por serología para infección chagásica y cuáles fueron sus diagnósticos. Se realizó un total de 1472 pruebas a pacientes individuales durante los 36 meses del período de estudio. De los 557 pacientes con serología positiva para Chagas, 97 (17.4%) fueron eventualmente hospitalizados en la Unidad Cardiológica. A su vez, estos 97 pacientes representaron el 33.7% de los 288 pacientes con cardiopatías. Entre los 97 con cardiopatía chagásica, 40 (41.2%) cumplieron criterios para colocación de marcapaso permanente, mientras que solo 13 de 191 (6.8%) enfermos con cardiopatías no chagásicas cumplieron esos criterios. La frecuencia de bloqueos auriculoventriculares asociados a infección por Trypanosoma cruzi resultó mucho mayor que las publicadas en estudios previos realizados en Sudamérica.

Abstract Chagas disease is endemic in Latin America and remains a regional problem despite improvements in en vironmental health conditions that have helped to control its transmission. To know more about its prevalence in heart disease patients, we carried out a survey in our national (El Salvador) reference hospital. We reviewed the Chagas Lab´s records 2013-2015 to find out how many of the patients admitted to the Hospital´s Heart Unit were serologically positives for Trypanosoma cruzi infection and which the associated diagnoses were. A total of 1472 patients were tested along the 36-month study period. Out of 557 (37.8%) patients with positive serology for Chagas infection, 97 (17.4%) were eventually admitted to the Heart Unit. Among these 97 Chagas infected patients with heart disease, 40 (41.2%) met the criteria for permanent pacemaker placement, while only 13 of 191 (6.8%) patients with non-chagasic heart disease met these criteria. The frequency of heart atrioventricular block associated with Trypanosoma cruzi infection was higher than frequencies reported in South American studies.

Características diferenciales del bloqueo interauricular avanzado típico y atípico / Differential characteristics of the typical and atypical advanced interatrial block

Resumen Objetivo: Se denomina bloqueo interauricular avanzado (BIA) a la existencia de una onda P ≥ 120 ms y bifásica +/- en las derivaciones inferiores (II-III-VF) del electrocardiograma (ECG) de superficie, el cual constituye un factor predictivo significativo del desarrollo de fibrilación auricular. En fecha reciente se han descrito cuatro patrones de BIA atípicos (BIA-At) con base en la morfología y la duración de la onda P, sin conocer si comparten patogenia y características clínicas similares. Método: Estudio observacional, descriptivo y retrospectivo de pacientes, visitados en el Servicio de Cardiología, en ritmo sinusal y con BIA. Las variables analizadas se obtuvieron de la historia clínica informatizada. El análisis de la onda P se efectuó al aumentar el tamaño del electrocardiograma y mediante calipers electrónicos. El análisis estadístico se realizó con SPSS 19.0, con nivel de significación de p < 0.05. Resultados: Se incluyó a 75 pacientes con media de edad de 74.4 ± 11.7 años, con 62.7% de varones. Se compararon los grupos de pacientes con BIA típico (BIA-T) y BIA-At. El primero se relacionó con la existencia de diabetes mellitus (p = 0.001), enfermedad renal crónica estadio ≥ 3 (p = 0.036), bloqueo auriculoventricular (p = 0.006) y una menor fracción de expulsión ventricular media (p = 0.025); no hubo diferencias respecto de la prevalencia de fibrilación auricular/flúter o accidente cerebrovascular. Sólo la diabetes se acompañó de riesgo de ser un BIA-T (OR: 6.4; p = 0.002; IC 95%: 2.0-21.1). Conclusiones: La diabetes mellitus constituye el único factor de riesgo de que un BIA sea típico. Los pacientes con BIA-T y BIA-At presentan similar prevalencia de fibrilación auricular y accidente cerebrovascular, por lo que son objeto de un mismo tratamiento clínico.

Abstract Objective: It is called advanced interatrial block (IAB) to the existence of a P wave ≥ 120 ms and biphasic ± in the lower leads II-III-VF of the surface electrocardiogram (ECG), which constitutes a significant predictive factor for the development of atrial fibrillation. Recently, four patterns of atypical aIAB (At-IAB) have been described based on the morphology and duration of the P wave, but it’s unknown if they share the same pathogenesis and clinical characteristics. Method: An observational, descriptive and retrospective study was performed with patients, visited in cardiology, who have a sinus rhythm and with aIAB. The analyzed variables were obtained from the computerized clinical history. The analysis of the P wave was made by increasing the size of the ECG and by electronic calipers. Statistical analysis was performed with SPSS 19.0; level of significance: p < 0.05. Results: A total of 75 patients with an average age of 74.4 ± 11.7 years and with a 62.7% males, were included. It was compared the group of patients with typical aIAB (T-aIAB) and with At-aIAB. The first one was associated with the existence of diabetes mellitus (p = 0.001), chronic kidney disease stage ≥ 3 (p = 0.036), atrioventricular block (p = 0.006) and a lower mean ventricular ejection fraction (p = 0.025); there were no differences regarding the prevalence of atrial fibrillation/flutter or stroke. Only diabetes was associated with the risk of T-aIAB (odds ratio: 6.4; p = 0.002; 95% confidence interval: 2.0-21.1). Conclusions: Diabetes mellitus is the only risk factor for an aIAB to be typical. Patients with T-aIAB and At-aIAB have a similar prevalence of atrial fibrillation and stroke, so they must follow the same clinical management.

Morbimortalidad cardiovascular y variación del grado funcional en pacientes ancianos portadores de marcapasos / Medium-long term mortality and change in functional status in elderly patients with pacemaker

Resumen Antecedentes: Aproximadamente un 49% de los implantes se efectúan a individuos mayores de 80 años; sin embargo, la evidencia científica sobre mortalidad y cambio en la situación funcional de estos pacientes es muy pobre. Objetivo: Diseñamos un estudio prospectivo para analizar la morbimortalidad cardiovascular y la variación de su grado funcional a medio plazo en pacientes ancianos con electroestimulación permanente. Método: Estudio observacional prospectivo, que incluye 308 pacientes ancianos sometidos a implante de marcapasos en un hospital terciario entre 2012 y 2014. Como variables principales se evaluaron eventos cardiovasculares, mortalidad y grado funcional, con una media de seguimiento de 3.5 años. Resultados: El 60% de los pacientes incluidos en nuestro estudio tenían una edad superior a 80 años, y la indicación más frecuente fue el bloqueo auriculoventricular completo (44.3%), seguido de la fibrilación auricular lenta o bloqueada (16.7%). El modo de estimulación más frecuente en la muestra general fue el DDD (38.6%) (VVI en pacientes octogenarios, 38.7%). En el seguimiento, la mortalidad a largo plazo fue mayor en dispositivos ventriculares, especialmente en octogenarios (p = 0.001). El modo de estimulación ventricular (VVI) fue predictor independiente de mortalidad. A largo plazo, no se observó mejoría del índice de Barthel ni del grado funcional tras el implante del marcapasos. Conclusiones: La morbimortalidad cardiovascular en pacientes octogenarios portadores de marcapasos resulta superior a la de la población general, especialmente en dispositivos monocamerales. La electroestimulación permanente no se asocia con mejoría del grado funcional a medio-largo plazo en estos pacientes.

Abstract Background: Nowadays, 49% of patients with pacemakers are older than 80 years old. Nevertheless, mortality and change in functional status after pacemaker implantation are not well documented in elderly patients. Objective: We designed a prospective study to analyze cardiovascular mortality and change in functional status of elderly patients, medium-long term after pacemaker implantation. Methods: Observational study including pacemaker implants in individual older than 70 years old in a single center university hospital between 2012 and 2014. Analysis testing for an association between pacemaker system, medium-long term mortality and functional status after implantation were undertaken. Results: 60% of patients were older than 80 years old. Third-degree atrio-ventricular block (44.3%) and slow ventricular response atrial fibrillation (16.7%) were the most frequent electrocardiogram abnormalities, while bicameral DDD was the sort of pacing our department used the most (38.6%) (VVI in octogenarian patients, 38.7%). Long-term mortality was significantly higher in ventricular devices, especially in octogenarian patients (p = 0.001 respectively). Single-chamber VVI pacing acted as independent predictors of all-cause mortality in these individuals (p = 0.001). We found no significant improvement in Barthel index and functional status in this subgroup of patients, 3 years after pacing. Conclusion: Long-term mortality in individuals older than 80 years old with pacemaker implantation, was significantly higher comparing with general population, especially in ventricular devices. No significant improvement in functional status was detected in this subgroup of patients.

Bloqueio atrioventricular no pós-operatório de cirurgia cardíaca valvar: incidência, fatores de risco e evolução hospitalar / Atrioventricular block in the postoperative period of heart valve surgery: incidence, risk factors and hospital evolution

INTRODUÇÃO: Distúrbios do sistema de condução cardíaco são complicações potenciais e conhecidas dos procedimentos de cirurgia cardíaca valvar. OBJETIVOS: Investigar a associação entre fatores peri-operatórios com bloqueio atrioventricular (BAV) e a necessidade de estimulação cardíaca artificial temporária (ECAT) e, se necessário, implante de marcapasso definitivo no pós-operatório de cirurgia cardíaca (POCC) valvar. MÉTODOS: Coorte histórica de pacientes submetidos a cirurgia cardíaca valvar, sendo realizada análise de banco de dados por regressão logística. RESULTADOS: No período de janeiro de 1996 a dezembro de 2008, foram realizadas 1102 cirurgias cardíacas valvares: 718 (65,2%) na valva aórtica e 407 (36,9%) na valva mitral; destas, 190 (17,2%) cirurgias de revascularização miocárdica associadas à cirurgia valvar e 23 (2,1%) cirurgias valvares combinadas (aórtica+mitral). Cento e oitenta e sete (17%) pacientes apresentaram quadro clínico e eletrocardiográfico de BAV durante o POCC valvar, necessitando de ECAT. Quatorze (7,5%) pacientes evoluíram para implante de marcapasso definitivo (1,27% do total da amostra). A análise multivariada evidenciou associação significativa de BAV com cirurgia de valva mitral (OR=1,76; IC 95% 1,08-2,37; P=0,002), implante de prótese biológica (OR=1,59; IC 95% 1,02-3,91; P= 0,039), idade maior que 60 anos (OR = 1,99; IC 95% 1,35-2,85; P<0,001), uso prévio de medicações antiarrítmicas (propafenona e amiodarona) (OR = 1,86; IC 95% 1,04-3,14; P=0,026) e uso prévio de betabloqueador (OR = 1,76; IC 95% 1,25-2,54; P=0,002). Embora a presença do BAV e necessidade de ECAT não tenham se associado a aumento de mortalidade, prolongaram a permanência hospitalar significativamente (P<0,0001) e, portanto, o consumo de recursos hospitalares. CONCLUSÃO: Esse estudo evidencia um conjunto de fatores preditivos potenciais a um perfil de pacientes que determinam alto risco de bloqueio atrioventricular e necessidade de estimulação ...

INTRODUCTION: Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES: This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS: Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS: Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P=0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P=0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P<0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P=0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P=0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P<0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS: Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.

Cardiac arrhythmias in Thai Acute Coronary Syndrome Registry.

BACKGROUND: The incidence of arrhythmic complications in Thai patients with acute coronary syndromes (ACS) has not been previously reported. The present study results will serve as the local database for future studies. OBJECTIVE: To evaluate the incidence of arrhythmic complications in ASC in Thai patients and to identify factors that may affect arrhythmia complications in ACS patients. MATERIAL AND METHOD: Data collected from 9,373 patients from the Thai acute coronary syndrome registry (TACSR) were analyzed. This registry includes patients who presented with ACS including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), within 14 days from the symptoms onset. RESULTS: 395 (4.2%) patients with an ACS presented after cardiac arrest. These patients were noted to have significantly higher in-hospital mortality (50.1%). The incidence of serious cardiac arrhythmia complications in the TACSR was 16.6%. Among them, 62.7% were sustained VT/VE 31.5% had second or third degree AV block, and 5.8% has both VT/VF and AV Block. The incidence of VT was higher in the younger age group, while AV block and arrhythmic death were higher in the older aged patients. Arrhythmias complicating ACS were associated with increased mortality risk. Congestive heart failure (CHF) within the first 48 hours, current use of tobacco and cardiac troponin elevation were associated with significantly higher arrhythmic complications during hospitalization. CONCLUSION: Arrhythmias complicating ACS were associated with higher in hospital mortality. CHF within the first 48 hr, current tobacco use and cardiac troponin elevation were associated with significantly higher arrhythmic complications.