Cirugía de la insuficiencia mitral isquémica / Surgery for ischemic mitral regurgitation

Background. Ischemic mitral regurgitation (IMR) is a severe condition which may be best treated by surgery, nowithstanding a relatively high mortality rate. Objectives. To evaluate the results of mitral valve replacement or repair in patients with IMR. Patients and methods. Retrospective review of the clinical records in 29 patients with IMR who were surgically treated from 1990 to 1999. They represent 8 percent of surgical procedures on the mitral valve. Results. Mean age was 67 ñ 9 years. Surgery was performed urgently in 19 patients (66,5 percent). NYHA functional class was 3.4 ñ 0.8. The mechanism of IMR was annular dilatation and spreading of papillary muscles in 18 patients, papillary muscle rupture in 9 and fibrosis in 2. Mitral valve replacement was performed in 14 patients and mitral valve repair in 15. Twenty four patients (83 percent) had concomitant myocardial revascularization. Overall surgical mortality was 24 percent; 26 percent for mitral replacement and 13 percent for mitral valve repair (p=0.215). On follow up of 26ñ33 months, one year survival was 76ñ0.8 percent and 5 years survival was 59ñ12 percent. Excluding in hospital mortality, survival was 100 percent at one year and 78ñ14 percent at 5 years. Functional class improved in all survivors, to 1.4ñ0.5. Late echocardiographic evaluation of patients with mitral valve repair showed absence of mitral regurgitation in 58 percent, 1+ MR in 17 percent and 2+ MR in 25 percent. Conclusion. In spite of a high perioperative mortality, surgery for IMR is a valuable procedure for patients with an otherwise highly lethal disease

Rechazo humoral en transplante cardíaco: comunicación de dos casos / Humoral rejection in heart transplantation: report of 2 cases

Heart transplantation is a therapeutic alternative for selected patients with refractory heart failure. Acute allograft rejection is one of the main causes of early death after transplantation. The cellular rejection is characterized by cellular infiltrates with or without miocyte necrosis. However, some patients develop left ventricular dysfunction due to rejection without evidence of cellular infiltration. In these patients, the rejection is mediated by antibodies and complement. Humoral rejection is a relative rare but potentially fatal form of acute allograft rejection. We report two patients with left ventricular dysfunction secondary to humoral rejection, shortly after cardiac transplantation. Both patients were treated with methylprednisolone, and azathioprine was substituted by cyclophosphamide. One patient underwent plasmapheresis. The clinical outcome was satisfactory and the left ventricular function returned to normal in both cases. The diagnostic and therapeutic strategies for the management of humoral rejection are reviewed

Heparina de bajo peso molecular versus heparina no fraccionada en el tratamiento de la angina inestable / Comparison of low molecular weight heparin and unfractionated heparin in the treatment of unstable angina

Background: Low molecular weight hepartin can be administered by the subcutaneous route and has stable and prolonged antithrombotic effect. These features have prompted clinical essays about its use as an alternative to unfractional heparin in the treatmen of unstable angina. Aim: To compare the clinical effects of low molecular weight heparin and unfractionated conventional heparin in patients with unstable angina or non Q infarction. Patients and methods: Seventy patients (47 male) admitted to the hospital with the diagnosis of unstable angina or non Q acute myocardial infarction were randomly assigned to receive unfractionated intravenous heparin or subcutaneous low molecular weight heparin bid. All received aspirin po and iv nitroglycerin. The incidence of recurrent angina, acute myocardial infarction or a need for emergency surgical revascularization during hospital stay were assessed in both groups. Results: Compared to patients with low molecular weight heparin, patients receiving unfractionated heparin had a higher incidence of recurrent resting angina (23 and 47.75 percent respectively, p< 0.04) and higher need for emergency surgical revascularization (3.3 and 17.5 percent respectively, p< 0.06). Patients treated with unfractionated conventional heparin had a 3 times higher risk of having an adverse cardiovascular event than patients receiving low molecular weight heparin (O.R. 0.33, confidence intervals 0.11-0.58). Conclusions: Low molecular weight heparin is superior to unfractionated conventional heparin in the treatment of unstable angina and non Q acute myocardial infarction

Ramipril vs espironolactona en el remodelamiento ventricular izquierdo post-infarto: estudio randomizado y doble ciego / Ramipril vs spironolactone in the left ventricular remodeling after infarction: randomized and double blind study

Patients and methods: Patients hospitalized for a first episode of acute myocardial infartion were blindly and randomly assigned to receive ramipril (2.5 mg bid), spironolactone (25 mg bid) or placebo. Ejection fraction, left ventricular en diastolic and end systolic volumes were measured by multigated radionuclide angiography, at baseline and after six months of treatment. Results: Twenty four patients were assigned to placebo, 31 to ramipril and 23 to spironolactone. Age, gender; Killip class, treatment with thrombolytics, revascularization procedures and use of additional medications were similar in the three groups. After six months of treatment, efection fraction increased from 34,5 ñ 2,3 to 4,2 ñ 2,4 percent in patients on ramipril, from 32,6 ñ 2,9 to 36,6 ñ 2,7 percent in patients on spironolactone, and decreased from 37 ñ 3 to 31 ñ 3 in patients on placebo (ANOVA between gropus p < 0.05). Basal end systolic volumen was similar in all three gropus, increased from 43,4 ñ 3,4 to 61,4 ñ 6,0 ml/m2 in patients on placebo and did not change in patients on spironolactone or ramipril (ANOVA p < 0.05). End diastolic volume was also similar in the three groups, increased from 70,6 ñ 4,3 to 92,8 ñ 6,4 ml/m2 in patients on placebo and did no change with the other treatments. Conclusions: Ramipril and spironolactone had similar effects on ventricular remodeling after acute myocardial infaction, suggesting that aldosterone contributes to this phenomenon and that inhibition of its receptor may be as effective as ACE inhibition in its prevention

Hormonas vasodilatadoras en la insuficiencia cardíaca crónica: efecto de la inhibición de la enzima convertidora de angiotensina / Vasodilator hormones in chronic heart failure: effect of the inhibition of angiotensine converting enzyme

To evaluate the chronic effect of enalapril, in addition to digitalis and diuretics, in patients with chronic heart failure, nine patients with an idopathic dilated cardiomyopathy (8 males, aged 48 to 76 years old) under treatment with digitalis and diuretics, received enalapril 20 mg bid during eigth weeks. Before and after this treatment period resting left ventricular ejection fraction, functional class, plasma levels of atrial natriuretic factor and bradykinins (BK) and urinary excretion of kalikreins (BK) and prostaglandins E2 (PGE2) were measured. After enalapril therapy, there was a significant increase in maximal O2 consumption (14.8ñ1.2 to 18.6ñ1.5 ml/kg/min, p<0.05) and radionuclide LV ejection fraction (27.4ñ1.1 to 31.4ñ0.9 percent p<0.05). This was associated with a significant decrease in plasma ANP levels (559ñ158 to 178ñ54.8 pg/ml) and UK (391ñ112 to 243ñ92 Cu/24 h). The decrease in ANP levels, which is a well known marker of prognosis in CHF, could contribute to explain the sustained clinical benefits observed with ACE inhibitors in patients with CHF

Edema pulmonar no-cardiogénico relacionado con la hidroclorotiazida / Non-cardiogenic pulmonary edema related to hidrochlorothiazide

A 54 years old female patient with a mitral valve prolapse and a rheumatic arthritis with steroids was admitted with dysnea and hypotension, that started 30 min after taking a pill containing enapril and hydroclorothiazide. Hemodynamic monitoring with a Swan-Ganz catheter showed a pulmonary capillary pressure of 5 mm Hg, a systemic vascular resistance of 887 (dyn sec)/cm5 and a cardiac output of 10 1/min. Tha patient had a history of adverse reactions to thiazides and responded to volume replacement, dopamine and steroids

Complicaciones del tratamiento trombolítico en pacientes con infacto del miocardio / Complications of thrombolytic therapy in patients with myocardial infarction

Analizamos en forma retrospectiva las complicaciones del tratamiento trombolítico observadas en 221 pacientes (pts) conseutivos con infarto del miocardio (IAM) y que fueron tratados con estreptoquinasa por vía sistémica (STK) dentro de las primeras 6 horas de evolución. La edad promedio fue de 61,5 años, la distribución por sexo H/M fue de 77/23 por ciento, la localización del IAM fue anterior en 49,5 por ciento e inferior en 51,5 por ciento, el tiempo promedio de inicio de tratamiento en relación al inicio de síntomas fue de 3,4 horas. En 37 pts (18 por ciento) se administró STK 1.000.000 de UI, en 46 pts (22 por ciento) STK 1.250.000 UI y en 128 pts (60,7 por ciento) 1.500.000 UI en un plazo de 30 minutos asociado con aspirina vía oral y seguida de heparina endovenosa. Las complicaciones por tratamiento con STK se calificaron en mayores (hipotensión severa que requirió drogas vasoactivas, shock anafiláctico, arritmias con compromiso hemodinámico y hemorragia cerebral) y menores (reacciones alérgicas locales, sangramiento en sitios de punción, hemorragia gastrointestinal u otra que no necesitará de transfusión). Se observaron complicaciones en 90 de los 221 pts (41 por ciento) tratados con STK: a) Mayores: hipotensión 15 por ciento, arritmias 7,2 por ciento, BAVC complicado 2 por ciento, shock anafiláctico 0,4 por ciento y hemorragia cerebral 0,9 por ciento. Menores: alergias 8,1 por ciento, braquidiarritmias 9,0 por ciento, hemorragia gastrointestinal 3 por ciento, equinosis 0,4 por ciento. No se observaron diferencias en cuanto a la presencia o ausencia de complicaciones según tiempo de evolución, dosis de STK administrada y localización de IAM. La mortalidad a las 48 horas post procedimiento tuvo una incidencia del 7,7 por ciento del total de pacientes y fue significativamente mayor en mujeres (p< 0,001) y en pacientes mayores de 75 años (p< 0,0001). De todas las complicaciones observadas, la más frecuente fue la hipotensión severa, que obligó al empleo de drogas vasoactivas y fue independiente de la dosis de STK. La incidencia de complicaciones registradas por administración de STK en el IAM es semejante a la reportada en la literatura

Ventilación mecánica no invasiva intermitente: utilidad en el tratamiento de la insuficiencia cardíaca crónica avanzada / Non invasive intermittent mechanical ventilation: utility in the treatment of advanced chronic cardiac failure

The higher respiratory work and less inspiratory muscle strength of patients with cardiac failure may contribute to dicrease their functional capacity. To assess the effects of non invasive intermittent mechanical ventilation on clinical parameters, peropheral perfusion, cardiac and inspiratory muscle function. Patients with chronic cardiac failure, functional cpacity III-IV were subjected to 6 sessions of nasal non invasive intermittent ventilation during 4 hours or to simulated ventilation (controls). Fifteen ventilated patients and 6 controls completed the protocol. Ventilated patients improved the mahler transition score for dysnea by 4ñ1.6 points. They also improved their aerobic capacity, increasing the exercise duration from 10.9ñ4 to 12.7ñ5 min and their maximal oxygen consumption from 14.6ñ4 to 16.4ñ5.7 ml/kg/min. These patients also decreased their O2 and CO2 ventilatory equivalents. Maximal inspiratory pressure increased from 67.9ñ23.6 to 80.19ñ21.4 cm H2O, sustained maximal inspiratory pressure increased from 101.4ñ48 to 133ñ53 cm H2O and maximal endurance increased from 132ñ52 to 162ñ58 g in ventilated patients. None of these variables was modified in control patients. No changes were observed in renal function, blood volume, arterial gases, spirometry or plasma catecholamine levels in any group. Intermittent nasal ventilation or other measures to improve inspiratory muscle function may be beneficial for patients with severe cardiac failure

Prueba de esfuerzo cardiopulmonar en pacientes con insuficiencia cardíaca crónica: comparación con sujetos normales y reproductibilidad de las mediciones / Cardiopulmonary exertion test in patients with chronic cardiac failure: comparison with normal people and reproducibility of measurements

The aim of this work was to measure oxygen consumption and carbon dioxide production during exercise in 21 subjects with cardiac failure and 13 normal subjects. During the resting period, subjects with cardiac failure had higher ventilatory frequency and respiratory quotient than normals. During maximal exercise, the former achieved higher ventilatory frequency and oxygen ventilatory equivalent than normals. In subjects with cardiac failure and normals, anerobic thresholds were 14,4ñ0,9 and 28,8ñ2,2 ml/kg/min respectively and peak oxygen consumptions 17,1ñ1 and 34,4ñ1,7 ml/kg/min respectively. There were less than 10 percent differences in parameters when tests were repeated in 10 subjects with cardiac failure. It is concluded that gas exchange testing may be a reliable and objective assessment method in patients with cardiac failure

Amrinona intravenosa en insuficiencia cardíaca refractaria: efectos clínicos, hemodinámicos y metabólicos / Amrinone in refractory congestive heart failure

En el presente trabajo se estudió si el beneficio de la infusión de Amrinona en pacientes con Insuficiencia Cardíaca Crónica Refractaria (ICCR) se relacionaba con modificación de la congestión visceral o de la perfusión tisular. Se estudiaron 10 pacientes (7 hombres, edad entre 52 y 77 años). La cardiopatía de base fue miocardiopatía dilatada idiopática en 7 pacientes, enfermedad coronaria en 1 y enfermedad reumática en 2 pacientes. El protocolo consistió en la infusión por 72 horas de Amrinona iv (promedio 10.2 ug/kg/min), además de diuréticos y digital. Se midieron antes e inmediatamente después de la administración de Amrinona diferentes parámetros: score clínico (SC), hemodinamia, dimensiones cardíacas (ECO 2D), índices de congestión visceral (peso corporal, congestión pulmonar radiológica y Volemia Plasmática), índices de perfusión tisular (ácido láctico arterial, clearance de creatinina y Flujo Plasmático Renal) y noradrenalina plasmática. Luego de la infusión de Amrinona mejoró el SC (12.8 ñ 0.5 vs 5.4 ñ 2.4, p < 0.009), y disminuyeron el peso (65.6 ñ 8.1 vs 63 ñ 9.5 kg, p < 0.05), Volemia Plasmática (2839 ñ 581 vs 2582 ñ 693 ml, p < 0.04) y la Presión Capilar Pulmonar (27.2 ñ 3.7 vs 17.9 ñ 7.0 p < 0.01). Aumentó el débito cardíaco (4.0 ñ 1.4 vs 5.1 ñ 2.1 lt/min, p < 0.05). No se observaron cambios significativos en el tamaño cardíaco, presión venosa central, resistencia vascular sistémica, flujo plasmático renal ni en noradrenalina plasmática. En estos pacientes, la terapia con Amrinona asociada a la terapia convensional, aumentó el gasto cardíaco, redujo la volemia y los parámetros de congestión visceral, lo que se asoció a mejoría clínica objetiva. Por otra parte, no observamos cambios significativos en los parámetros de perfusión tisular