Endocarditis infecciosa: morbimortalidad en Chile: resultados del estudio cooperativo nacional de endocarditis infecciosa, ECNEI, 1998-2002 / Mortality and complications of infective endocarditis in Chile: results of the national cooperative study of infective endocarditis, 1998-2002

Infective endocarditis is a severe condition, with a mortality that fluctuates between 16 and 25 percent in the Metropolitan area of Chile. Aim: To perform a prospective assessment of clinical and microbiological features of patients with infective endocarditis in Chile. Material and methods: Collaborative study of regional hospitals in the whole country and teaching hospitals in Santiago. Patients with a possible or definitive infective endocarditis, according to Duke's criteria, were included in the protocol and a structured data entry form was completed. Results: Three hundred twenty one patients (65 percent male, mean age 49ñ16.5 years) were studied. According Duke's criteria, 89 percent had a definitive and 11 percent a possible endocarditis. The subacute form occurred in 64 percent of patients. The most frequent predisposing cardiopathies were rheumatic in 25 percent, prosthetic valves in 15 percent and congenital in 13 percent. There was no evidence of cardiopathy in 20 percent. Twenty percent of patients were on hemodialysis, 11 percent were diabetic and only one patient abused intravenous drugs. The most frequent complication was cardiac failure in 59 percent of cases, followed by renal failure in 32 percent and embolism in 28 percent. The most frequent causing organism was coagulase positive Staphylococcus in 35 percent. Blood cultures were negative in 28 percent of cases from the metropolitan region, in 56 percent of cases from the north and 38 percent of cases from the south. Echocardiographic diagnosis was done in 92 percent of cases. Aortic valve was involved in 42 percent and mitral valve in 29 percent. Successful antimicrobial treatment was achieved in 59 percent of patients. Thirty five percent of patients were subjected to surgical procedures with a 78 percent survival. Overall mortality was 29 percent. Univariate analysis identified sepsis, an age over 60 years and the presence of cardiac or renal failure as prognostic indicators of mortality. On multivariate analysis, the identified prognostic indicators were the presence of sepsis, renal failure, mitroaortic involvement associated to combined surgery and failure of antimicrobial treatment not associated to surgery. Conclusions: Subacute form is the most common presentation of infective endocarditis and rheumatic valve disease is the most common underlying cardiac lesion. The most frequent causing agent is coagulase positive Staphylococcus...

Fibrilación auricular focal: características clínicas y resultado de la ablación con radiofrecuencia / Results of radiofrequency ablation in focal atrial fibrillation

Background: Atrial fibrillation can originate in arrhythmogenic foci coming from the pulmonary veins. Patients with atrial fibrillation, initiated from triggering foci, can be treated with radiofrequency ablation. Aim: To report the results of radiofrequency ablation in patients with focal atrial fibrillation. Patients and methods: Thirteen patients with focal atrial fibrillation (8 male, aged 19 to 60 years old) are reported. Twelve had frequent crises refractory to antiarrhythmic drugs. Two had also flutter and tachycardia. One had a permanent atrial fibrillation lasting five years. Two had ventricular dysfunction and left atrial dilatation. The triggering focus was identified during the electrophysiological study, by the precocity of the potential that initiated the atrial fibrillation. Results: All patients had early atrial extrasystolic beats, isolated or repetitives, that preceded atrial fibrillation. During the electrophysiological study, 18 foci (3 in the right and 15 in the left atrium all in pulmonary veins) were identified. Radiofrequency ablation had immediate success in 11 patients. In 5, a flutter was also ablated. One patient had a sinus dysfunction after the procedure and atrial fibrillation was not eliminated. In this and other patient in whom the procedure failed, a pacemaker was implanted and the atrioventricular node was blocked. In a follow up, ranging from 4 to 31 months, eight patients are asymptomatic and 3 recidivated. No complications have been detected. Conclusions: Patients with focal atrial fibrillation have common clinical and electrocardiographic features. Radiofrequency ablation of the triggering focus is possible and effective in most cases

Estudio comparativo de la angioplastia coronaria en pacientes con diabetes: resultados clínicos y angiográficos inmediatos y evolución clínica en el primer año / Comparative study of coronary angioplasty in diabetic patients: clinical and angiographic results and clinical evolution at 1 year of follow up

Background: The success of revascularization procedures for coronary artery disease could be lower in diabetic patients. Aim: To report the results of coronary angioplasty in diabetic and non diabetic patients. Patients and methods: All angioplasty procedures performed between 1996 and 1999 were recorded. Demographic data, procedure details, hospital outcome and evolution at one year of follow up were analyzed. Results: During the study period, 358 patients were treated; of these, 79 were diabetics. Despite the greater severity of coronary lesions among diabetic patients the clinical success of the procedure was 92.4 percent in diabetics and 91.8 percent in non diabetics. Hospital mortality was 1.3 pecent in diabetics and 0.7 percent in non diabetics. Major complications occurred in 3.8 percent of diabetics and 3.2 percent in non diabetics. One year survival was 95.9 percent for diabetics and 98 percent in non diabetics. There were five late cardiac deaths among non diabetics and 3 among diabetics during the year of follow up. The frequency of new revascularization procedures was 4.3 percent in diabetics and 8.3 percent in non diabetics. Event-free survival was 95.6 percent in diabetics and 89.2 percent in non diabetics. Conclusions: Results of angioplasty were similar in diabetic and non diabetic patients in terms of hospital outcome and late follow-up

La clasificación de lesiones coronarias de la Society for Cardiac Angiography and Interventions, predice mejor el éxito de la angioplastía coronaria que la del American College of Cardiology/American Heart Association / Prediction of coronary angioplasty success using different coronary artery lesion scores

Background. The classification of coronary lesion complexity, using the American College of Cardiology/American Heart Association (ACC/AHA) is a predictor of balloon angioplasty success. Stents have improved results even in complex lesions. Aim. To compare the ACC/ AHA and the new Society for Cardiac Angiography (SCA&I) coronary lesion scores as predictors of angioplasty success. Patients and Methods. Al' consecutive angioplasty procedures (n=346, 456 lesions, 47 per cent stents) were prospectively analized from August 1996 to March 1999. Coronary lesions were classified using the ACC/AHA and SCA&I scores. Angiographic success was assesed and its multivariate predictors determined with logistic regression analysis. Results. According to the ACC/AHA score, angiographic success was 97, 92.7, 93.3, and 82.3 per cent in A, Bl, B2 and C lesions respectively (p=0.013). There only were significant differences in success between C and A, Bl or B2 lesions. According to the SCA&I score success was achieved in 97.3, 97.9, 75.8 and 33.3 per cent in nonCP, CP, nonCO and CO lesions respectively (P<0.001). With the SCA&I score statistically significant differences in angiographic success were found for all lesion score comparisons, except between nonCP and CP lesions. No other variables had predictive value for angiographic success. Conclusions. Coronary angioplasty angiographic success is better predicted by the new SCA&l lesion score than with the ACC/AHA lesion clasification in a group of patiens with frequent use of stents

Implante de prótesis endovasculares (stents) en el tratamiento de la cardiopatía coronaria: resultados angiográficos, clínicos inmediatos y tardíos / Endovascular stent placing in the treatment of coronary artery disease: angiographic, immediate and late clinical results

Background: Coronary revascularization allows a better survival and quality of life in high risk patients with coronary artery disease. Aim: To report the experience in stent placement as treatment for obstructive atherosclerotic coronary artery disease. Patients and methods: A prospective analysis of 105 stent placements. A morphological and quantitative analysis of coronary angiograms, using an electronic caliper, was performed. Patients were followed during their hospital stay and after discharge. Results: In four of 112 coronary lesions, it was not possible to liberate the stent and in 108, it was successfully placed (48 in anterior descending, 19 in circumflex, 36 in right coronary arteries and 5 in saphenous aortocoronary by-pass. Lesions with stent implantation were type A in 11 percent, B1 in 30 percent, B2 in 44 percent and C in 15 percent. Reference diameter was 3.13 ñ 0.58 mm. After placement, luminal diameter increased from 0 95 ñ 0.43 to 2.99 ñ 0.46 mm, with a final stenosis of 7.2 ñ 10.1 percent. Angiographic success was obtained in 99 percent and procedure success in 98 percent. Hospital mortality was 0.98 percent. After a mean of eight months follow up, 91 percent of patients is free of major cardiac events. In 17 percent angina recurred and 5 percent required a new revascularization. There were no late cardiac deaths, acute stent thrombosis or infarction in relation to the treated lesion. Conclusions: In these patients, stent placement has had excellent immediate and late results

Endocarditis infecciosa: factores pronósticos de mortalidad en 131 casos / Infectious endocarditis: prognostic factors of mortality in 131 cases

We followed during their hospital stay, 129 patients aged 14 to 74 years old, who had 131 episodes of infective endocarditis. Clinical assessment, echocardiography and microbiological study was done to all patients. Surgical indications were those derived from complications. Thirty three patients died during hospital stay (25.2 percent). There were no differences between survivors and deceased patients in the lapse between onset of symptoms and hospital admission, presence of fever, dyspnea or heart murmurs. Skin and mucosal septic manifestations occured with higher frequency in deceased patients (57.1 and 24.3 percent respectively). Blood cultures were positive in 55 percent in survivors and 48 percent in those who died. The most frequent infecting organisms were staphilococci and streptococci. Vegetations were found with greater frequency in aortic position in both groups of patients. Deceased patients had a higher frequency of cardiac failure (84 and 65 percent respectively) and embolic episodes (77 and 46 percent respectively) than survivors. Antimicrobial treatment was successfull in 94 percent of survivors and 15 percent of those who died. Forty percent of survivors and 54 percent of deceased patients were subjected to surgical procedures. The most important predictor of hospital mortality in this series of patients with infective endocarditis was antimicrobial treatment failure

Las subespecialidades médicas en Chile: situación actual / Medical subspecialties in Chile: current status

There is no reliable registry of medical subspecialties in Chile. According to the records of the Autonomous National Corporation for Certification of Medical Specialties (CONACEM), the largest number of certifications is in internal medicine (n=681), followed by cardiology (n=153), respiratory medicine (n=106), gastroenterology (n=93), endocrinology (n=77), rheumatology (n=55), hematology (n=50), nephrology (n=50), and infectious diseases (n=31). Over 55 percent of those certified in internal medicine and 70 percent of those certified in medical subspecialties (except nephrology) live in the metropolitan region of Santiago. Almost 80 percent of university-trained internists have received their training at the University of Chile (1952-1995), whereas 52 percent of university-trained subspecialists have been trained at the Catholic University of Chile. A sizeable number of non official training programs are conducted at some universities at variance with their own official training policies. In internal medicine, a larger number of specialists have been trained by the universities that are certified by CONACEM, whereas the converse is true for medical subspecialists. More than 80 percent of the internists in Chile work for the Ministry of Health, who cares for 70 percent of the country's population. The best internist population ratio is in Arica and Valdivia and the poorest one in Arauco and in Viña del Mar/Quillota. According to estimations done by the Santiago Medical Society and its subspecialty affiliate societies, an adequate proportion of internists would be 1 for every 10.000 inhabitants and for subspecialists, 1 for every 100.000 inhabitants. More information is needed about the ideal distribution throughout the country. CONACEM needs to be strengthened, the universities should be able to certify non-university training centers and the migration of subspecialists out of Santiago should be encouraged