Estrategia fármaco-invasiva en el manejo del infarto agudo al miocardio con supradesnivel del ST / Pharmaco-invasive approach in the management of acute myocardial infarction. Analysis of 144 cases

BACKGROUND: In those patients who do not have timely access to primary angioplasty, the pharmaco-invasive approach, that is, the use of thrombolysis as a bridging measure prior to the coronary angiography, is a safe alternative. AIM: To describe the features of patients with an acute ST-elevation myocardial infarction (STEMI) treated with a pharmaco-invasive strategy. MATERIAL AND METHODS: Descriptive observational study of 144 patients with mean age of 46 years with STEMI who received a dose of thrombolytic prior to their referral for primary angioplasty at a public hospital between 2018 and 2021. RESULTS: There were no differences the clinical presentation according to the Killip score at admission between thrombolyzed and non-thrombolyzed patients (p = ns). Fifty-three percent of non-thrombolyzed patients were admitted with an occluded vessel (TIMI 0) compared with 27% of thrombolyzed patients (p < 0.001). The thrombolyzed group required significantly less use of thromboaspiration (3.5 and 8.4% respectively; p = 0.014). Despite this, 91 and 92% of non-thrombolyzed and thrombolyzed patients achieved a post-angioplasty TIMI 3 flow. Long-term survival was 91 and 86% in thrombolyzed and non-thrombolyzed patients, respectively (p = ns). CONCLUSIONS: The pharmaco-invasive strategy is a safe alternative when compared to primary angioplasty in centers that don't have timely access to Interventional Cardiology.

Implante de válvula aórtica percutánea con técnica de sedación consciente / Transfemoral transcatheter aortic valve implantation under conscious sedation: experience in 15 patients

Background: Transfemoral transcatheter aortic valve implantation (TAVI) is the standard of treatment for patients with symptomatic severe aortic stenosis (AE) and intermediate or high surgical risk. The use of conscious sedation (CS) could reduce complications and allow an early discharge of these patients. Aim: To report our experience with TAVI under conscious sedation. Material and Methods: Review of medical records of 15 patients aged 79 ± 6 years (53% women) undergoing a transfemoral TAVI implant under conscious sedation. Results: The indications for the procedure were severe AE in 13 patients and biological prosthetic dysfunction in two. The mean Thoracic Surgeons predicted risk of mortality score was 7.3. The valves used were Edwards Sapien 3 in three patients, Medtronic Evolut in five, Boston Acurate Neo in four and Meril Myval in three. A successful implant was achieved in all cases and there were no hospital mortality or pacemaker requirements. One patient had a stroke, and one patient had a vascular access complication. Early discharge (< 72 h) was achieved in 80% of patients. Conclusions: TAVI under conscious sedation was a safe procedure and associated with a complication rate similar to previous reports, allowing for an early hospital discharge in most patients.

Resultados a largo plazo de la valvuloplastía mitral con balón / Long term results of mitral balloon valvuloplasty

Background: Mitral balloon valvuloplasty (MBV) is the therapy of choice for the treatment of symptomatic mitral stenosis with suitable anatomy. Although its short and mid-term results are favorable, there is a paucity of information about long-term follow-up. Aim: To assess the late results of MBV. Material and Methods: A cohort of 225 patients aged 8 to 20 years who were subjected to a MBV from 1989 to 2001, was studied. All variables at the time of the procedure, short and long-term results and major events during follow-up (new mitral intervention and mortality) were recorded. Uni and multivariate analysis were used to assess prognosis. Results: The mean follow-up lapse was 13.5 years (range 8 to 20 years). During this period, 88 patients (39.1%) remained event-free and in acceptable functional capacity. Eight percent died, 8% required a second MBV and 43.5% required a surgical mitral valve replacement. A post-procedural area equal or greater to 1.9 cm² was associated with a greater likelihood of free-event survival (log rank test: p = 0.02/Cox proportional regression model: coefficient 0.54, p = 0.04). Conclusions: MBV is effective, although there is a high chance of new interventions in the long-term follow-up. A larger post-procedure mitral area is associated with a better prognosis.

Angina secundaria a lesión de tronco coronario izquierdo post trasplante cardiaco: Evidencias de reinervación simpática tardía / Angina after a heart transplant with evidence of late sympathetic reinnervation: Report of one case

We report a 56 years-old man presenting with chest pain with exercise, seven years after an orthotopic heart transplant. A coronary angiography showed an atherosclerotic lesion in the common left main coronary artery with more than 90 percent obstruction. The lesion was successfully treated with a transluminal angioplasty with stenting. A 131-1 metaiodobenylguanidine (MIBG) scan demonstrated sympathetic reinnervation. Sixteen months later, due to progression of allograft vasculopathy, coronary artery bypass was required.

Función de los músculos inspiratorios, parámetros hemodinámicos y disnea en pacientes con estenosis mitral / Inspiratory muscle function, hemodynamic parameters and dyspnea in patients with mitral valve stenosis

Background: The mechanism involved in dyspnea in patients with mitral valve stenosis (MS) is not completely understood. Aim: To evaluate in patients with MS, changes in hemodynamic parameters during the assessment of inspiratory muscle endurance (IME) and the relationship between IME, hemodynamics and dyspnea. Subjects and methods: We studied 13 patients (9 in NYHA class II and 4 in class III). Endurance was evaluated using a two minute incremental threshold loading test, to obtain the maximal sustainable inspiratory pressure (SIP), and maximal inspiratory load (MIL). During the test, cardiac output (CO), mean pulmonary and capillary pressures (PAP and PCP, respectively), were evaluated. Results: Compared to six normal subjects, MS patients had reduced SIP and MIL (p <0.01), which correlated with baseline index of dyspnea (r= 0.57 and r=0.52, respectively, p <0.05). At the end of the test period, basal CO, cardiac index (CI), PAP and PCP increased from 3.4 to 4.0 l/min-1; 2.1 to 2.5 l/min-1/m-2; 15 to 25 and 11 to 18 mmHg, respectively (p <0.01). No relationship between IME and hemodynamic parameters was found. Conclusions: IME is reduced and is closely related to dyspnea in these patients with MS. The observed low CI, suggests that muscle underperfusion could contribute to this dysfunction during the inspiratory effort.

Utilidad de isosorbide sublingual en la reversibilidad de la hipertensión pulmonar reactiva, en pacientes candidatos a trasplante cardíaco / Usefulness of sublingual isosorbide to assess the reversibility of pulmonary hypertension in cardiac transplant candidates

Background: Continuous infusion of short life vasodilators are employed to test reversibility of pulmonary hypertension in cardiac transplant candidates. Sublingual isosorbide administration has not been described in the literature and it might be a simpler alternative. Aim: To evaluate sublingual isosorbide administration as a test of reversibility of pulmonary hypertension in heart failure. Patients and Methods: Prospective evaluation of patients referred for cardiac transplant evaluation. Patients underwent right catheterization for hemodynamic measurements at baseline and after repeated doses of 5 mg sublingual isosorbide every 5 minutes until observing a decrease in pulmonary vascular resistance decrease or symptomatic hypotension. Results: Twenty one patients, 18 men, age 49±15 years, were studied. Fourteen (66%) were transplanted. The mean sublingual isosorbide dose was 15±5 mg. After isosorbide administration, there was a significant decrease in mean arterial pressure (80±8.5 to 71±6.6 mmHg, p <0.0001), mean pulmonary artery pressure (38±11 to 26±7.8 mmHg, p <0.0001), systemic vascular resistance (1540±376 to 1277±332 dyn*s/cm5 p <0.001), pulmonary vascular resistance (3.5±2.2 to 2,5±1.6 Wood Units, p <0.05) and transpulmonary gradient (13±7 a 10±4 mmHg, p <0.004). The cardiac output increased from 3.96±0.7 to 4.38±0.9 L/min, p=0.05. The relation between pulmonary and systemic vascular resistance before and after isosorbide was 0.17 and 0.15, respectively (p=0.04). One transplanted patient with partial reversibility of pulmonary hypertension developed acute right heart failure. Conclusions: Sublingual isosorbide administration is useful and well tolerated to evaluate the reversibility of pulmonary hypertension prior cardiac transplant.

Tratamiento de la insuficiencia cardíaca avanzada mediante trasplante de corazón / Heart transplantation as a treatment for advanced heart failure

Background: Heart transplantation currently provides the most effective treatment for advanced heart failure. However, medical therapy for this condition has also improved, heart donors are scarce and the cost of the procedure is high. Therefore the indications and management of these patients need reevaluation. Aim: To analyze the results of 24 patients submitted to heart transplantation for end-stage heart failure needing repeated hospitalizations and i.v. inotropes for compensation. Patients and methods: The group was comprised by 21 men and 3 women with a mean age of 36.8 years, mean left ventricular ejection fraction 19ñ4.5 percent, mean systolic pulmonary artery pressure 48ñ13 mmHg (24-70) and mean pulmonary vascular resistance 2.6 Wood Units (1-5). Fourteen patients (58 percent) had a previous median sternotomy. Immunosupression did not include induction therapy and steroids were discontinued early...

Mejoría de la función muscular inspiratoria en pacientes con estenosis mitral cerrada después de valvuloplastia mitral percutánea: comunicación preliminar / Improvement in inspiratory muscle function after percutaneous mitral valvuloplasty in mitral stenosis: preliminary report

Background: It has been proved that there is an inspiratory muscle dysfunction in mitral stenosis; Although its causes still remain unknown. Aim: to evaluate the effect of percutaneous balloon mitral valvuloplasty (PMV) on inspiratory muscle performance (IMP) in patients with mitral stenosis (mitral area < 1.5 cm2). Patients and methods: We studied IMP in 8 patients (35 ñ 10 years) before and 3 months after successful PMV. Inspiratory muscle strength was studied by measuring maximal statistical inspiratory mouth pressure (MIP). Endurance was evaluated using a two minute incremental threshold loading test in order to obtain the maximal sustainable inspiratory pressure (SIP), with the maximal sustainable load (MSL) the patients could sustain for 2 minutes. Results: Mitral valvuloplasty increased mean cardiac index from 3.1 ñ 0.3 to 4.15 ñ 0.3 l/min/m2 (p<0.01), and significantly decreased mean pulmonary and capillary pressures. The MIP value(118 ñ 6 cmH2O), similar to that of normal group, increased to 137 ñ 7 cmH2O (p<0.01). SIP and maximal sustainable load were 52 ñ 3 cmH2O and 294 ñ 29 g respectively, lower than normal subjects (p<0.05) They increased after PMV to 80 ñ 3 cmH2O and 463 ñ 26 g respectively (p<0.001). Conclusions: PMV improved inspiratory muscle function in patients with severe mitral stenosis, probably secondary to a decrease work of breath and improvement of ventricular function