Experience with Percutaneous Transcatheter Closure of Interatrial Communications at the Cardiovascular Center of Puerto Rico and the Caribbean.

OBJECTIVE: The annual rate of percutaneous transcatheter closure of atrial septal defects (ASDs) and patent foramen ovales (PFO) has markedly increased in the United States over the past decade. This technique has been used at the Cardiovascular Center for Puerto Rico and the Caribbean since 2005. We report on the clinical characteristics and the immediate and short-term follow-up of adult patients who underwent this procedure at this center from 2008 to 2012. METHODS: One hundred and two consecutive medical records of adult Hispanic patients who underwent this procedure at our center from 2008 to 2012 were identified. A retrospective analysis of the clinical characteristics and the immediate and short-term clinical and echocardiographic follow-up of those patients was performed. RESULTS: The study population comprised 70 women and 32 men, with a mean age of 51 years (age range: 19 to 80 years). Of those, 43 (42%) underwent ASD closure and 60 (59%), closure of a PFO. A 99% procedural success rate was achieved. There were only 3 procedural complications, including the failure of the initial implantation of 1 device, which required the endovascular removal of that device and the implantation of another, a hematoma at the vascular access site, and 1 brief episode of atrial fibrillation. CONCLUSION: Based on our review of the available records, we were able to determine that the percutaneous transcatheter closure of interatrial communications proved to be, at our institution, a safe procedure with a high success rate and a low incidence of in-hospital complications. To our knowledge, this is the first report on the utilization of this interventional procedure in Puerto Rico.

Giant coronary aneurysms in a young adult patient with Kawasaki disease.

Kawasaki disease is an acute, self-limited vasculitis of childhood and the principal cause of acquired heart disease in children in several parts of the world. Its major morbidity and mortality is related to the development of coronary aneurysms. The long-term impact of this disease in adults is not known, however, clinically silent coronary artery aneurysms may be recognized after a sudden cardiac event, even death. We report a case of Kawasaki disease in a young asymptomatic Puerto Rican man who presented to our Adult Cardiology Clinic with multiple giant coronary aneurysms. A brief review of the epidemiology, etiology, pathophysiology, clinical features, therapeutic modalities, prognosis and complications of this condition is also included.

Review of clinical characteristics and management of patients with ST segment elevation myocardial infarction at atertiary care center.

BACKGROUND: Information from recent multiple trials on the pathophysiology and outcome of ST-segment elevation myocardial infarction (STEMI) has changed its clinical perspective and strategic management, leading to a revision of the 1999 ACC/AHA practice guidelines for that condition. OBJECTIVE: Analyze the clinical characteristics, management strategies, the timing of therapeutic interventions and outcome of patients with STEMI referred to the Cardiovascular Center of Puerto Rico (CVCPR). METHODS: Retrospective review of medical records of all patients admitted to the CVCPR with a diagnosis of STEMI from January 1, 2003 to December 31, 2003. RESULTS: A total of 184 medical records were reviewed. Seventy-six percent of patients were men, mean age was 62.1 +/- 11.8 years. A high prevalence of coronary risk factors was present: systemic hypertension (64%), diabetes mellitus (40%), dyslipidemia (35%), smoking (33%) and previous CAD (32%). Less than 1/4 of referral forms contained data indicative of whether patients had received antiplatelet therapy, beta-blockers, ACE inhibitors or statins. Fifty percent of patients arrived to the CVCPR more than 48 hours after diagnosis. Only forty-two patients (23%) arrived within 12 hours. Thrombolytic therapy had been used in 27% of them. 179 (97%) patients underwent coronary angiography, 69.2% of which had multivessel disease. 114 (62%) patients underwent percutaneous coronary interventions (PCI) with stenting. Patients submitted to PCI and stenting of the culprit lesion had a better outcome and survival than the ones not exposed to those procedures (p = 0.02). Approximately two-third of patients received secondary prevention medications upon discharge. CONCLUSIONS: Relevant findings of this review were that in spite of high prevalence of CAD major risk factors, the use of medications of proven benefit for prevention and treatment of CAD at referral centers was less than that recommended by current guidelines, a significant delay in the transfer of patients to the tertiary care facility (in most cases that period exceeded more than 48 hours after diagnosis) and a reduced utilization of thrombolytic therapy. Intensification of the education of physicians throughout the island regarding these matters is to be encouraged. Additional measures should include, development of written protocols at referral centers to assure a more expedite clinical assessment of patients, an enhancement of their capability for utilizing fibrinolytic agents in suitable candidates and the timely transfer to PCI-capable facilities of patients that may still benefit from catheter reperfusion.

Heart diseases during pregnancy.

Improvements in health care services in recent decades have permitted more frequent identification of pregnant women with congenital and acquired heart disease. Normal pregnancy and the peripartum period are associated with considerable cardiocirculatory changes, which are usually well tolerated by the mother. However, the increased cardiac demands imposed by those changes may at times unmask cardiac disease in presumably normal women or increase morbidity and mortality in women with established heart disease. A recognition and understanding of these changes is essential for providing optimal care to obstetrical patients with cardiac disorders. This article offers a brief review of those cardiocirculatory changes during pregnancy and of the main features of various congenital and valvular heart disorders frequently referred for advice to our cardiology practice, along with recommendations for their management and follow up.

Acute heart failure in adults.

Heart failure (CHF) is one of the most important health problems of our population and surprisingly the only cardiovascular disorder whose prevalence, incidence and mortality is steadily rising in spite of extraordinary advances in the diagnosis and management of other forms of cardiac disease. Management of chronic CHF has been the focus of recently published guidelines by cardiovascular societies both in the United States and Europe. However, no analogous guidelines have so far addressed the management of acute CHF. This presentation aims to review current knowledge regarding the diagnosis and management of acute CHF, to promote a more accurate identification of this clinical disorder and an optimization of the care received by patients afflicted with this condition in our community.

Effect of right atrial pacing, intravenous amiodarone and beta blockers for suppression of atrial fibrillation after coronary artery bypass surgery: a pilot study.

OBJECTIVE: This pilot study aimed to compare right atrial pacing, intravenous amiodarone and oral beta-blockers in the prevention, time to onset, duration and effect on hospital stay of postoperative atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) at our center. BACKGROUND: AF is the most common arrhythmic complication after CABG and is related to increased morbidity, length of hospital stay and costs. Trials with different drugs and other therapeutic modalities including beta-blockers, intravenous amiodarone and override suppression of automatic atrial foci by atrial pacing have shown partial success as preventive measures. However, a comparison between those three interventions has not been reported. METHODS: Thirty-six consecutive patients that underwent CABG at our institution were randomly assigned to atrial pacing (18 patients) and intravenous amiodarone (18 patients) after baseline clinical, electrocardiographic and hemodynamic assessment. All patients received concomitant oral metoprolol or atenolol right after extubation. Thirty-three patients who had CABG at our center in the previous two months and that only received beta-blockers during their perioperative period served as a control group. RESULTS: The majority of baseline clinical and hemodynamic characteristics were similar in all groups. Only one patient (5.6%) developed AF in the atrial pacing group versus five (27.8%) on amiodarone and six (18.2%) who only received beta-blockers. That finding, however, did not attain statistical significance (p > 0.05). After adjusting for potential confounders, the odds of occurrence of AF was 77% lower in atrial pacing patients (OR = 0.23; 95% CI: 0.02, 2.20; p = 0.09) and 2.36 times higher in those on amiodarone (95% CI: 0.55, 10.24; P = 0.053) when compared to patients which only received beta blockers. Since only one patient on right atrial pacing developed atrial fibrillation, the analysis of the median time to onset and median duration of atrial fibrillation was restricted to those assigned to amiodarone and those who only received beta-blockers showing no statistically significant differences (p > 0.05). Although no statistical significance was achieved, the median hospital stay was one-day shorter in the beta-blockers group. Most of the side effects were minor and resolved without sequelae. CONCLUSION: This pilot study showed a trend in favor of atrial pacing versus intravenous amiodarone or beta-blockers in the prevention of postoperative AF after CABG in our center. Randomization of a larger patient sample would be required in order to ascertain the true value of the observed trend.

The hyperlipidemias.

Despite clear and consistent clinical-trial evidence establishing a causal link between lipid disorders and coronary heart disease and that cholesterol-lowering therapy dramatically reduces the risk for that disease and its complications, many patients for whom such treatment is indicated remain either unidentified or untreated. Our objective is to present updated, practical information for primary-care physicians on the evaluation and management of lipid disorders, particularly those related to the primary and secondary prevention of coronary heart disease, the leading cause of morbidity and mortality in our population. A pertinent summary of the guidelines contained in the Third Report of the National Cholesterol Expert Panel on Detection, Evaluation and Treatment of Cholesterol in Adults (Adult Treatment Panel III), commonly known as ATP III, is utilized to better fulfill that objective.

Gender differences in clinical outcome after coronary stenting

OBJECTIVE: The purpose of this study was to determine the effect of gender differences in the clinical outcome of women and men submitted to coronary stenting at our institution. BACKGROUND: Studies regarding gender differences in outcome after invasive coronary interventions have revealed conflicting data regarding risk for complications. Some studies have pointed to female gender as a predictor of mortality and complications after those procedures. To our knowledge no such evaluation has been performed in our country. METHODS: We reviewed the medical records, cardiac catheterization and procedural data of 205 men and 122 women referred to our section that underwent coronary stenting at the Cardiovascular Center of Puerto Rico and the Caribbean from July 1, 1998 to March 30, 1999. The clinical and procedural characteristics and the immediate procedure-related complications were analyzed. Clinical events during the six-month period after the procedure were evaluated in patients that returned for follow-up to the section. Student's t-test or Mann-Whitney-Wilcoxon, when appropriate, was used to compare continuous data. The chi-square test or Fisher's exact test, was employed to compare categorical data. RESULTS: The initial procedural success and the frequency of early complications were comparable to those informed in the medical literature and not statistically significant between genders. The only statistically significant gender differences in outcome occurred in men who had higher re-hospitalization and re-intervention rates in the six-month period after the procedure. A lower mean ejection fraction and higher previous history of myocardial infarction and cigarette smoking in this group could have been related to the higher complication rate. CONCLUSION: Although the sample examined is small, its findings point to the need of a larger prospective study to further explore the possibility that the previously reported differences in outcome in men and women submitted to interventional procedures would have a stronger relation to clinical factors than to the direct effect of gender.

Surgical versus interventional procedures in patients with multivessel coronary artery disease

OBJECTIVE: This study examined the clinical characteristics, risk factors, indications and post-intervention complications of patients with multivessel coronary artery disease (CAD) submitted to either percutaneous transluminal coronary angioplasty (PTCA) and/or stent placement versus isolated coronary artery bypass grafting (CABG). BACKGROUND: Several studies have examined the relative safety and outcome of patients submitted to those interventional procedures compared to CABG. Limited information is available regarding that subject in Puerto Rico. METHODS: We performed a retrospective analysis of the clinical, angiographic, operative, interventional, post-operative and post-interventional data of patients submitted to those procedures in our institution from January 1998 to August 1998. There were 53 patients in the interventional group and 206 patients in the CAGB group. Comparison of quantitative variables by procedure was based on Student t test or Mann-Whitney-Wilcoxon test; categorical variables were compared using Pearson's chi-square or Fisher's exact test. RESULTS: There were no significant differences in age, body surface area, or cardiac risk factors. The most common pre-existing cardiovascular diagnosis was unstable angina. Three-vessel disease was the most common angiographic finding among CABG patients (61.7 percent). Two-vessel disease without left anterior descending coronary artery obstruction was significantly more common in the PTCA/Stent patients (58.5 percent). The vast majority (97.6 percent) of patients in the PTCA/Stent group and 52.4 percent of the CABG group had two-vessel intervention. A significantly higher frequency of complications occurred in the CABG group. However, the incidence of major complications, in both groups was not statistically different. Atrial arrhythmias were significantly more frequent in the CABG group. CONCLUSION: A larger prospective study should be conducted in order to corroborate these preliminary findings and seek effective solution to any identifiable problem.

Dilated cardiomyopathy: a clinical review of patients evaluated at a Tertiary Care Center in Puerto Rico

OBJECTIVES. The purpose of this study was to determine the causes, epidemiologic baseline data and clinical characteristics of a group of patients referred to a tertiary care center in Puerto Rico with the diagnosis of dilated cardiomyopathy.METHODS. The medical records of 91 new patients with the diagnosis of dilated cardiomyopathy were analyzed. Data was recopilated regarding initial medical history and physical examination, basic blood chemistry, electrocardiograms, chest films and other cardiac studies including echocardiogram, radionuclear ventriculography, cardiac catheterization, contrast ventriculography and coronary angiography. After reviewing the records the etiology for dilated cardiomyopathy was identified in each patient following the World Health Organization Task Forcecriteria. RESULTS. Ischemic cardiomyopathy was identified as the most common the reviewed patient population; an idiopathic etiology was found cause of dilated cardiomyopathy, representing 37 percent of in 22 percent of the patients and valvular heart disease in 14 percent. DISCUSSION. A comparison with previously described series in the medical literature regarding this subject is presented, along with the most prominent clinical characteristics of the studied population. It is felt that the findings presented will require further study of the underlying causes and clinical course of this condition in a larger patient sample and a longer follow-up period

Immunological aspects in various forms of shock

Se presenta un repaso sobre los aspectos inmunológicos en tres formas del síndrome clínico de shock: anafiláctico, séptico y cardiogénico. Se hace una discusión de la participación de los derivados del ácido araquidónico, de la activación del sistema de complemento y de los efectos de los mediadores producidos por diferentes células que explican el origen de varias de las manifestaciones clínicas de estas tres entidades