Chronic angina secondary to Takayasu arteritis. Report of one case / Síndrome coronario crónico secundario a aortitis y enfermedad coronaria ostial bilateral. Informe de un caso

Chronic coronary syndromes are usually considered uncommon in young women, related to slower progression of atherosclerotic coronary artery disease, have atypical clinical presentations, and experience less diagnostic investigation. Non-atherosclerotic causes of coronary artery disease should be considered in young women experiencing angina. We report a 25-year-old woman who consulted for five months of moderate exertion angina. Physical examination revealed a right carotid bruit and asymmetrical upper extremity peripheral pulses. Initial work-up and imaging allowed to diagnose aortitis with bilateral coronary ostial stenosis secondary to Takayasu's arteritis. The patient experienced an apparent clinical response to initial medical therapy. However, follow-up evaluation revealed persistence of significant ischemia and requirement for myocardial revascularization. A percutaneous coronary intervention was performed.

Los síndromes coronaries crónicos son infrecuentes en mujeres jóvenes, quienes suelen presentar una lenta progresión de enfermedad coronaria aterosclerótica, tienen presentación clínica atípica y son menos sujetas a exploración diagnostica. Se deben considerar causas no ateroscleróticas de enfermedad coronaria en mujeres jóvenes con angina. Informamos una paciente de 25 años que consultó por cinco meses de angina con esfuerzos moderados. Al examen físico presentaba un soplo carotideo derecho y pulsos asimétricos de extremidades superiores. La exploración de laboratorio inicial y posterior evaluación multimodal permitió evidenciar la presencia de aortitis y estenosis de ambos ostium coronarios, concordante con el diagnóstico de una arteritis de Takayasu. Inició terapia medica con respuesta clínica aparentemente favorable. No obstante, la evaluación cardiológica no invasiva en el seguimiento permitió corroborar la persistencia de isquemia significativa y necesidad de revascularización miocárdica. Se realizó una intervención coronaria percutánea de ambos ostium, con una evolución favorable.

Consequences of COVID-19 pandemic on myocardial infarction reperfusion therapy and prognosis / Consecuencias de la pandemia COVID-19 en la reperfusión y pronóstico del infarto de miocardio

ABSTRACT Background The coronavirus disease (COVID-19) pandemic affected the prompt diagnosis and treatment of Acute myocardial infarction (AMI). Aim: To characterize the clinical profile of patients with AMI during the COVID-19 pandemic, comparing them with a historical cohort. Material and Methods: A case-control study of 96 patients with AMI transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March and July 2020, and a historical cohort of 269 patients transferred during the same period in 2019. Results: When comparing patients transferred during the pandemic with those of the historical cohort, the former were younger (63 ± 12 vs 68 ± 12 years, p 12 hours from the onset of symptoms (44 vs 0%, p < 0.01), a higher median door-to-device time (4 vs 3 hours, p < 0.01), a higher use of primary percutaneous coronary intervention (97 vs 71%, p < 0.01), and higher frequencies of cardiogenic shock (20 vs 4%, p < 0.01) and mechanical complications (10% vs 2%, p < 0.01). Patients during COVID pandemic had a higher thirty-day overall (20 vs 1.4%, p < 0.01) and cardiovascular mortality (13 vs 1%, p < 0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for thirty-day overall mortality (Risk ratio 2.90; 95% confidence intervals 1.14-7.36). Conclusions: During the pandemic patients with AMI exhibited delays in consultations and treatment, higher morbidity, and increased mortality. COVID-19 positivity was associated to worse thirty-day overall survival.

Antecedentes: La pandemia COVID-19 afectó el tratamiento oportuno del infarto agudo de miocardio (IAM). Objetivo: Caracterizar el perfil clínico de pacientes con IAM durante la pandemia COVID-19 y compararlos con una cohorte histórica. Pacientes y Métodos: Estudio caso-control de 96 pacientes con IAM transferidos a un hospital de alto volumen de intervención coronaria percutánea (ICP) entre marzo julio de 2020 y una cohorte histórica de 269 pacientes transferidos en el mismo período de 2019 (n = 269). Resultados: Al comparar los pacientes transferidos durante pandemia y la cohorte histórica, los primeros eran más jóvenes (63 ± 12 y 68 ± 12 años respectivamente, p 12 h desde iniciados síntomas de IAM con elevación ST (44,4 y 0% respectivamente, p < 0,01), una mediana de tiempo puerta-guía mayor (4 y 3 horas respectivamente, p < 0,01), un mayor uso de ICP primaria (97 y 71% respectivamente, p < 0,01), mayor frecuencia de shock cardiogénico (19,8 y 4,1% respectivamente, p < 0.01) y complicaciones mecánicas (10,4 y 1,7% respectivamente, p < 0,01). A treinta días, los primeros tuvieron mayor mortalidad general (19,8 y 1,4% respectivamente p < 0.01) y cardiovascular (12,5 y 1,4% respectivamente, p < 0,01). Durante la pandemia, 40% de los pacientes presentó positividad para COVID-19, siendo un factor predictivo de mortalidad general (razón de riesgo 2,90; intervalos de confianza 95% 1,14-7,36). Conclusiones: Durante la pandemia, hubo retrasos en tiempos de consulta y tratamiento y mayor morbimortalidad del IAM. La positividad de COVID-19 se asoció a peor sobrevida general a treinta días.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology

ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.

Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico

Background: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. Aim: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. Material and Methods: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. Results: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. Conclusions: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

Peritonitis fúngica por Rhodotorula mucilaginosa en una paciente en diálisis peritoneal automatizada: revisión de la literatura / Fungal peritonitis due to Rhodotorula mucilaginosa in a patient with automated peritoneal dialysis: literature review

Fungal peritonitis is a major complication of peritoneal dialysis associated with high mortality. Most survivors have a high rate of abandonment of peritoneal dialysis. We report a case of fungal peritonitis due to an unusual agent. An 83 year-old woman, with a history of type 2 diabetes mellitus and multiple episodes of bacterial peritonitis associated to technical flaws in the implementation of automated peritoneal dialysis, was admitted due to abdominal pain and cloudy peritoneal fluid. Rhodotorula mucilaginosa was identified in the peritoneal fluid by MALDI-TOF. She was treated with catheter removal and oral posaconazole for 14 days showing clinical resolution and non-recurrence.

La peritonitis fúngica es una complicación mayor de la diálisis peritoneal, con una alta mortalidad asociada y la mayoría de los sobrevivientes presentan una alta tasa de abandono de diálisis peritoneal como terapia de reemplazo renal. Se presenta un caso de peritonitis fúngica por un agente infrecuente. Mujer de 83 años, diabética con múltiples episodios de peritonitis bacteriana asociada a fallas técnicas en la ejecución de diálisis peritoneal automatizada, ingresa por cuadro clínico de dolor abdominal y líquido peritoneal turbio. Se confirmó la presencia de Rhodotorula mucilaginosa en líquido peritoneal mediante MALDI-TOF. Fue tratada con retiro del catéter y posaconazol oral por 14 días, presentando una evolución favorable.

Características, manejo y evolución intrahospitalaria de usuarios de drogas ilícitas con infarto agudo del miocardio / Characteristics, management, and outcomes of illicit drug consumers with acute myocardial infarction

Background: Consumption of illicit drugs (ID) has been associated with an increased risk of acute myocardial infarction (AMI). There is limited national evidence about the impact of substance use over the clinical presentation, management and outcomes of AMI patients. Aim: To describe the prevalence of ID consumption in patients within the Chilean Registry of Myocardial Infarction (GEMI), comparing clinical characteristics, management and outcome according to consumption status. Material and Methods: We reviewed data from the GEMI registry between 2001 and 2013, identifying 18,048 patients with AMI. The sample was stratified according to presence or absence of previous ID consumption, comparing different demographic and clinical variables between groups. Results: Two hundred eighty five patients (1.6%) had history of ID consumption (cocaine in 66%, cannabis in 35% and central nervous system stimulants in 24.0%). Compared with non-users, ID consumers were younger, predominantly male and had a lower prevalence of cardiovascular risk factors, except for tobacco smoking (86.3% and 42.5% respectively, p < 0.01). Among consumers, there was a higher percentage of ST segment elevation (85.2% and 67.8% respectively, p < 0.01) and anterior wall AMI (59.9 and 49.5% respectively, p = 0.01). Additionally, they had a higher rate of primary angioplasty (48.8% and 25.5% respectively, p < 0.01). There was no difference in hospital mortality between groups when stratified by age. Conclusions: A low percentage of patients with AMI had a previous history of ID consumption in our national setting. These patients were younger and had a greater frequency of ST segment elevation AMI, which probably determined a more invasive management.

Resultados a largo plazo del trasplante intracoronario de células mononucleares de médula ósea autólogas en pacientes con cardiopatía dilatada de diversa etiología / Long-term results of intracoronary transplantation of autologous bone marrow cells in dilated cardiomyopathy

Background: Intracoronary delivery of autologous bone marrow mononuclear cells is an interesting therapeutic promise for patients with heart failure of different etiologies. Aim: To evaluate the long-term safety and efficacy of this therapy in patients with dilated cardiomyopathy of different etiologies under optimal medical treatment. Patients and Methods: Prospective, open-label, controlled clinical trial. Of 23 consecutive patients, 12 were assigned to autologous bone marrow mononuclear cell intracoronary transplantation, receiving a mean dose of 8.19 ± 4.43 x 10(6) CD34+ cells. Mortality, cardiovascular readmissions and cancer incidence rate, changes in functional capacity, quality of life questionnaires and echocardiographic measures from baseline, were assessed at long-term follow-up (37.7 ± 9.7 months) in patients receiving or not the cells. Results: No significant differences were observed in mortality, cardiovascular readmissions or cancer incidence rate amongst groups. An improvement in functional class and quality of life questionnaires in the transplanted group was observed (p < 0.01). The treated group showed a non-significant increase in left ventricular ejection fraction at long-term follow-up (from 26.75 ± 4.85% to 34.90 ± 8.57%, p = 0.059 compared to baseline). There were no changes in left ventricular volumes. We observed no improvement of these variables in the control group. Conclusions: Intracoronary transplantation of autologous bone marrow mononuclear cells is feasible and safe in patients with dilated cardiomyopathy of diverse etiologies. This therapy was associated to persistent improvements in functional class and quality of life. There was also a non-significant long-term improvement of left ventricular function.

Estado actual de la terapia con células madre en el tratamiento de las cardiopatías / Stem cells for the treatment of cardiovascular diseases. An update

Available medical therapy is unable to completely prevent or revert the pathological cardiac remodeling secondary to ischemia or other injuries, which is responsible for the development of heart failure. Regenerative medicine through stem cells had an explosive development in the cardiovascular area during the past decade. Stem cells possess the capacity to regenerate, repair or substitute damaged tissue, allowing the reestablishment of its function. Stem cells can also modulate apoptosis, angiogenesis, fibrosis and inflammation, favoring the endogenous regenerative process initiated by the damaged tissue. These capacities have been corroborated in several animal models of cardiovascular diseases with positive results. In humans, therapies with bone marrow mononuclear stem cells, mesenchymal stem cells and cardiac stem cells are safe. Most randomized clinical trials in patients with myocardial infarction or cardiomyopathies of different etiologies have reported benefits on ventricular function, quality of life and even over mortality of treated patients. This article reviews the state of art of stem cell therapy in cardiovascular diseases, focusing on the most common cellular types used in patients with acute myocardial infarction and chronic cardiomyopathies of different etiologies.

Aplicaciones y proyecciones de los antagonistas del receptor de mineralocorticoides en el tratamiento de patologías cardiovasculares / Mineralocorticoid receptor antagonists and therapeutic strategies of cardiovascular damage

In recent years, much attention has focused on the role of aldosterone and mineralocorticoid receptors (MRs) in the pathophysiology of hypertension and cardiovascular disease. Patients with primary aldosteronism, in whom angiotensin II levels are low, have a higher incidence of cardiovascular complications than patients with essential hypertension. The Randomized Aldactone Evaluation Study (RALES) demonstrated that adding a non-specific MR antagonist, spironolactone, to a standard therapy that included angiotensin-converting enzyme (ACE) inhibitors, loop diuretics, and digoxin, significantly reduced morbidity and mortality in patients with moderate to severe heart failure. Similarly, the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) showed that the addition of a selective MR antagonist (ARM), eplerenone, to an optimal medical therapy reduces morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure. These data suggest that aldosterone induces cardiac injury through activation of MRs and support the notion that MR blockade has beneficial effects on aldosterone-dependent cardiac injury, through mechanisms that cannot be simply explained by hemodynamic changes. Although, MRA are highly effective in patients with heart failure, the risk of hyperkalemia should not be overlooked. Serious hyperkalemia events were reported in some MRA clinical trials; however these risks can be mitigated through appropriate patient selection, dose selection, patient education, monitoring, and follow-up.