Prevalence and prognostic significance of pulmonary artery aneurysms in adults with congenital heart disease.

BACKGROUND: Prevalence and prognostic significance of pulmonary artery (PA) dilatation in congenital heart disease (CHD) have never been studied systematically. METHODS: Chest X-rays of 1192 consecutive adults with CHD were reviewed. Major diameter of the PA was determined by imaging techniques in those with PA dilatation. A value >29 mm was considered abnormal. Data on anatomy, hemodynamics, residual lesions and outcomes were retrospectively collected. RESULTS: Overall prevalence of PA dilatation was 18%. A minority of patients (5.5%) reached 40 mm (aneurysm; PAA) and 1.8% exceeded 50 mm. The most common PAA underlying malformations were pulmonary stenosis (21%), and shunts (55%). Significantly larger diameters were observed in hypertensive shunts (40 mm; IQR 36.7-45 mm vs. 34 mm; IQR 32-36 mm) (p < 0.0001). However, the largest diameters were found in cono-truncal anomalies. There was no significant correlation between PA dimensions and systolic pulmonary pressure (r = -0.196), trans-pulmonary gradient (r = -0.203), pulmonary regurgitation (PR) (r = 0.071) or magnitude of shunt (r = 0.137) (p > 0.05 for all). Over follow-up, 1 sudden death (SD) occurred in one Eisenmenger patient. Complications included coronary (3), recurrent laryngeal nerve (1) and airway (1) compressions, progressive PR (1), and PA thrombosis (1). Coronary compression and SD were strongly associated (univariate analysis) with pulmonary hypertension (120 vs. 55 mm Hg; p = 0.002) but not with extreme PA dilatation (range: 40-65 mm). CONCLUSIONS: PA dilatation in CHD is common but only a small percentage of patients have PAA. Clinical impact on outcomes is low. Complications occurred almost exclusively in patients with pulmonary hypertension whereas PA diameter alone was not associated with adverse outcomes.

Percutaneous intervention in chronic total coronary occlusions caused by in-stent restenosis: procedural results and long-term clinical outcomes in the TORO (Spanish registry of chronic TOtal occlusion secondary to an occlusive in-stent RestenOsis) multicentre registry.

AIMS: Limited data exist on the treatment and outcomes of patients with chronic total occlusions due to in-stent restenosis (CTO-ISR). We sought to evaluate results and clinical outcomes in percutaneous interventions over CTO-ISR. METHODS AND RESULTS: We conducted a registry in 16 centres involving consecutive patients undergoing attempted percutaneous intervention over CTO-ISR. A total of 233 patients were included, 192 (82.4%) with a successful acute result. The success rate was significantly lower in patients with: lesion in the circumflex artery, ostial lesions, J score >3 and no femoral access. The presence of tandem lesions (OR 0.19, 95% CI: 0.06-0.68; p=0.01) was identified as an independent predictor for outcome. After a median follow-up of 20 months, cardiac death in the successful vs. failed groups was 3% and 8.3%, respectively (p=0.09). Independent predictors for mortality were previous CABG (HR 8, 95% CI: 1.3-50; p=0.02) and multivessel disease (HR 2.3, 95% CI: 1.2-4.3; p=0.01). In the successful group, TLR was 15%, re-occlusion 6% and definite/probable stent thrombosis 1.8%. CONCLUSIONS: Percutaneous treatment of CTO due to ISR in contemporary practice shows a high success rate, resulting in good long-term results. The angiographic and procedural predictors identified may contribute to improving procedural outcome through better patient selection.

Eficacia de un programa de tratamiento de la hiperglucemia en un Servicio de Cirugía Vascular supervisado por Endocrinología / Efficacy of a hyperglycemia treatment program in a Vascular Surgery Department supervised by Endocrinology

INTRODUCCIÓN: El objetivo de este estudio fue evaluar las estrategias terapéuticas utilizadas y la eficacia de un programa de tratamiento de la hiperglucemia supervisado por Endocrinología. MÉTODOS: Estudio retrospectivo de todos los pacientes con diabetes tipo II ingresados en Cirugía Vascular en un periodo de 12 meses. Registramos las características clínicas y los datos relacionados con el tratamiento de la hiperglucemia durante la hospitalización, al alta y a los 2-6 meses postalta. El control glucémico se evaluó mediante los perfiles glucémicos y la HbA1c al ingreso y a los 2-6 meses postalta. RESULTADOS: Se incluyeron 140 hospitalizaciones de 123 pacientes. El protocolo para la selección de la pauta de insulina se aplicó en el 96,4% de los pacientes (22,8% correctora; el 23,6% basal-correctora y 50% basal-bolo-correctora [BBC]). Los pacientes con BBC tenían HbA1c inicial (7,7 ± 1,5% frente a 6,7 ±0 ,8%; p < 0,001) y glucemia media el día del ingreso más elevadas (184,4& #177; 59,2 frente a 140,5 ±31,4 mg/dl; p < 0,001). La glucemia media se redujo en la mitad (162,1 ±41,8 mg/dl) y en las últimas 24 h del ingreso (160,8 ±43,3 mg/dl) en los pacientes con BBC (p = 0,007), pero no se modificó en el resto. En el 22,1% de los pacientes en los que se realizaron modificaciones del tratamiento previo al alta, la HbA1c se redujo de 8,2±1,6 a 6,8±1,6%, a los 2-6 meses postalta (p = 0,019). CONCLUSIONES: La aplicación por personal experto del protocolo de tratamiento de la hiperglucemia en el hospital permite identificar el tratamiento adecuado y mejorar el control glucémico durante la hospitalización y al alta, confirmando su eficacia en condiciones de práctica clínica

BACKGROUND: The aim of this study was to evaluate the strategy and efficacy of a hyperglycemia treatment program supervised by Endocrinology. METHODS: All patients with type 2 diabetes hospitalized at the vascular surgery department over a 12 month period were retrospectively reviewed. Clinical characteristics and hyperglycemia treatment during hospitalization, at discharge and 2-6 month after discharge were collected. Glycemic control was assessed using capillary blood glucose profiles and HbA1c at admission and 2-6 months post-discharge. RESULTS: A total of 140 hospitalizations of 123 patients were included. The protocol to choose the insulin regimen was applied in 96.4% of patients (22.8% correction dose, 23.6% basal-correction dose and 50% basal-bolus-correction dose [BBC]). Patients with BBC had higher HbA1c (7.7 ± 1.5% vs. 6.7 ± 0.8%; P < .001) and mean glycemia on the first day of hospitalization (184.4 ± 59.2 vs. 140.5 ± 31.4 mg/dl; P < .001). Mean blood glucose was reduced to 162.1 ± 41.8 mg/dl in the middle and 160.8 ± 43.3 mg/dl in the last 24 h of hospitalization in patients with BBC (P = .007), but did not change in the remaining patients. In 22.1% patients with treatment changes performed at discharge, HbA1c decreased from 8.2 ± 1.6 to 6.8 ± 1.6% at 2-6 months post-discharge (P = .019). CONCLUSIONS: The hyperglycemia treatment protocol applied by an endocrinologist in the hospital, allows the identification of the appropriate therapy and the improvement of the glycemic control during hospitalization and discharge, supporting its efficacy in clinical practice

Efficacy of a hyperglycemia treatment program in a Vascular Surgery Department supervised by Endocrinology. / Eficacia de un programa de tratamiento de la hiperglucemia en un Servicio de Cirugía Vascular supervisado por Endocrinología.

BACKGROUND: The aim of this study was to evaluate the strategy and efficacy of a hyperglycemia treatment program supervised by Endocrinology. METHODS: All patients with type 2 diabetes hospitalized at the vascular surgery department over a 12 month period were retrospectively reviewed. Clinical characteristics and hyperglycemia treatment during hospitalization, at discharge and 2-6 month after discharge were collected. Glycemic control was assessed using capillary blood glucose profiles and HbA1c at admission and 2-6 months post-discharge. RESULTS: A total of 140 hospitalizations of 123 patients were included. The protocol to choose the insulin regimen was applied in 96.4% of patients (22.8% correction dose, 23.6% basal-correction dose and 50% basal-bolus-correction dose [BBC]). Patients with BBC had higher HbA1c (7.7±1.5% vs. 6.7 ±0.8%; P<.001) and mean glycemia on the first day of hospitalization (184.4±59.2 vs. 140.5±31.4mg/dl; P<.001). Mean blood glucose was reduced to 162.1±41.8mg/dl in the middle and 160.8±43.3mg/dl in the last 24h of hospitalization in patients with BBC (P=.007), but did not change in the remaining patients. In 22.1% patients with treatment changes performed at discharge, HbA1c decreased from 8.2±1.6 to 6.8±1.6% at 2-6 months post-discharge (P=.019). CONCLUSIONS: The hyperglycemia treatment protocol applied by an endocrinologist in the hospital, allows the identification of the appropriate therapy and the improvement of the glycemic control during hospitalization and discharge, supporting its efficacy in clinical practice.

PREDIRCAM eHealth platform for individualized telemedical assistance for lifestyle modification in the treatment of obesity, diabetes, and cardiometabolic risk prevention: a pilot study (PREDIRCAM 1).

BACKGROUND: Healthy diet and regular physical activity are powerful tools in reducing diabetes and cardiometabolic risk. Various international scientific and health organizations have advocated the use of new technologies to solve these problems. The PREDIRCAM project explores the contribution that a technological system could offer for the continuous monitoring of lifestyle habits and individualized treatment of obesity as well as cardiometabolic risk prevention. METHODS: PREDIRCAM is a technological platform for patients and professionals designed to improve the effectiveness of lifestyle behavior modifications through the intensive use of the latest information and communication technologies. The platform consists of a web-based application providing communication interface with monitoring devices of physiological variables, application for monitoring dietary intake, ad hoc electronic medical records, different communication channels, and an intelligent notification system. A 2-week feasibility study was conducted in 15 volunteers to assess the viability of the platform. RESULTS: The website received 244 visits (average time/session: 17 min 45 s). A total of 435 dietary intakes were recorded (average time for each intake registration, 4 min 42 s ± 2 min 30 s), 59 exercises were recorded in 20 heart rate monitor downloads, 43 topics were discussed through a forum, and 11 of the 15 volunteers expressed a favorable opinion toward the platform. Food intake recording was reported as the most laborious task. Ten of the volunteers considered long-term use of the platform to be feasible. CONCLUSIONS: The PREDIRCAM platform is technically ready for clinical evaluation. Training is required to use the platform and, in particular, for registration of dietary food intake.

Radial compression guided by mean artery pressure versus standard compression with a pneumatic device (RACOMAP).

BACKGROUND: Transradial access is the approach of choice in many laboratories for diagnostic coronariography or percutaneous coronary interventions (PCI) because of its lower vascular complication rate than the femoral approach. However, this approach has a higher rate (5-10%) of asymptomatic radial artery (RA) occlusion. METHODS: We conducted a prospective, controlled, single-centre trial study. We investigated whether the pneumatic compression (using "TR Band of Terumo") of the radial artery guided by the mean artery pressure (MAP) after the procedure (group A) is efficient in reducing radial occlusion in patients under a coronary angiography by transradial access for diagnostic coronariography or PCI compared to use of standard procedure (group B, 15 cm(3) of air in the device). RESULTS: The study was suspended after analyzing the results of 50% of the scheduled patients. An analysis of the results of 351 consecutive random patients in Group A showed significantly (P = 0.0001) lower rate (1.1%) of occlusion than Group B (12.0%) without significant differences in the rate of other complications. Other variables associated with RA occlusion in univariate analysis were previous or active smoker (P < 0.04), absence of anti-aggregant treatment (P < 0.04), and the presence of RA flow postprocedure (PFP, P < 0.001). Independent predictors with logistic regression analysis were PFP (HR = 0.06, 95% CI 0.01-0.2), presence of hematoma (HR = 3.7, 95% CI 1.2-11.0), and standard pneumatic compression in group B patients (HR = 18.8, 95% CI 3.8-92.2). CONCLUSIONS: Use of pneumatic compression guided by MAP is safe and efficient, and it can significantly lower the incidence of radial artery occlusion.

The MUSIC Risk score: a simple method for predicting mortality in ambulatory patients with chronic heart failure.

AIMS: The prognosis of chronic heart failure (CHF) is extremely variable, although generally poor. The purpose of this study was to develop prognostic models for CHF patients. METHODS AND RESULTS: A cohort of 992 consecutive ambulatory CHF patients was prospectively followed for a median of 44 months. Multivariable Cox models were developed to predict all-cause mortality (n = 267), cardiac mortality (primary end-point, n = 213), pump-failure death (n = 123), and sudden death (n = 90). The four final models included several combinations of the same 10 independent predictors: prior atherosclerotic vascular event, left atrial size >26 mm/m(2), ejection fraction < or =35%, atrial fibrillation, left bundle-branch block or intraventricular conduction delay, non-sustained ventricular tachycardia and frequent ventricular premature beats, estimated glomerular filtration rate <60 mL/min/1.73 m(2), hyponatremia < or =138 mEq/L, NT-proBNP >1.000 ng/L, and troponin-positive. On the basis of Cox models, the MUSIC Risk scores were calculated. A cardiac mortality score >20 points identified a high-risk subgroup with a four-fold cardiac mortality risk. CONCLUSION: A simple score with a limited number of non-invasive variables successfully predicted cardiac mortality in a real-life cohort of CHF patients. The use of this model in clinical practice identifies a subgroup of high-risk patients that should be closely managed.

Expression of activation molecules in neutrophils, monocytes and lymphocytes from patients with unstable angina treated with stent implantation.

Coronary angioplasty is known to mediate an inflammatory response. Recently, we have characterized the transient systemic inflammatory response after coronary stent implantation in patients with unstable angina by measuring different soluble protein markers. In the present study we have characterized the expression of various cellular activation markers in neutrophils, monocytes and lymphocytes from the same group of patients. Peripheral blood samples were taken before and 24 h, 48 h and 7 days after successful coronary stenting in 58 patients. Cell surface markers (CD11b/CD18 and CD38) were analyzed by flow cytometry to determine the activation of neutrophils, monocytes and T lymphocytes. We found that coronary angioplasty with stent implantation produces an increase in the cell surface expression of CD11b/CD18 in neutrophils and CD38 in monocytes, following a similar time-course with a peak after 24 h, returning to basal levels after 48 h and a second peak after 7 days. However, T lymphocytes were not found to be activated. These results suggest that coronary stent implantation induces a different pattern inducing soluble and cellular inflammation markers, and therefore, they should be taken into account in patients undergoing stent implantation to study clinical correlations.

Endothelial nitric oxide synthase gene polymorphism in dialysis patients.

Nitric oxide is an important factor in the regulation of vasodilator tone. In vascular cells, NO is synthesized by endothelial nitric oxide synthase, a key enzyme of the endogenous vasodilator system. Some studies have described the interaction between NO and the other factors that promote vasodilatation in vascular smooth muscular cells. Some of those factors are angiotensin-converting enzyme (ACE), transforming growth factor beta (TGF beta), and endothelial oxide nitric synthase (eNOS). Polymorphism that can alter the expression or the function of the eNOS protein has been identified in the eNOS gene in the promoter and codification zones. We studied the Glu298Asp variant of the eNOS gene in 52 hemodialysis (HD) patients, 22 peritoneal dialysis (PD) patients, and 93 healthy controls. Identification of the Glu298Asp variant in exon 7 was performed by enzymatic amplification and restriction fragment length polymorphism (RFLP) analysis. The frequencies of eNOS genotypes in the control group were GG, 39.8%; GT, 43%; and TT, 17.2%. In HD patients, the frequencies were GG, 40.3%; GT, 38.7%; and TT, 21.7%. In PD patients, they were GG, 41.6%; GT, 50%; and TT, 8.6%. No significant differences were seen between the control group and the dialysis patients, or between the HD and the PD patients.

Inflammatory response to coronary stent implantation in patients with unstable angina.

Previous evidence has shown that coronary angioplasty leads to the release of inflammatory mediators. In this study, we sought to characterize the systemic inflammatory response after coronary stent implantation in patients with unstable angina by measuring different protein markers. Peripheral blood samples were taken before and 24 h, 48 h, and 7 days after successful coronary stenting in 58 patients. Several markers of acute-phase response were determined: C-reactive protein (CRP), alpha2-macroglobulin, haptoglobin, acid alpha1-glycoprotein, prealbumin and albumin. Besides, proinflammatory cytokines (tumor necrosis factor-alpha, IL-6, IL-8) and the anti-inflammatory cytokine IL-10 were also measured. We have found that coronary angioplasty with stent implantation produces a systemic inflammatory response with a rise in inflammation markers concentration. CRP plasma levels declined 1 week after the intervention, but the other marker levels were even higher after 7 days. IL-6 was the only cytokine whose plasma levels significantly increased in peripheral blood after stenting, with a rise after 24 h, maintained after 48 h, and decreased to near-basal levels after 1 week. There was a good correlation between CRP and IL-6 plasma levels (r=0.5, p<0.001). IL-10 levels were slightly decreased after 24 h. Although no significant differences in the means at different time points were found, there was a decrease in IL-10 in most patients 24 h after the intervention. These results indicate that coronary stent implantation induces a systemic inflammatory reaction, with a temporal increase in the concentration of the inflammation markers, especially CRP and IL-6. Since these markers had been previously used as prognostic markers, this needs to be taken into account in patients undergoing stent implantation.

Arrhythmogenic right ventricular cardiomyopathy and atrial right-to-left shunt.

A 47-year-old woman diagnosed with arrhythmogenic right ventricular cardiomyopathy, was studied at our institution with palpitations, progressive dyspnoea and cyanosis over a 3-year period. Her haemoglobin saturation was 76.1%. The transthoracic echocardiogram showed that both right atrium and ventricle were dilated, with diffuse akinetic and hypokinetic areas. Radionuclide scintigraphy, angiography and magnetic resonance imaging showed dilated and severe dysfunction of the right ventricle, with depressed ejection fraction (0.16), and bulging at the level of the right ventricular anterior wall areas. Doppler examination revealed a right-to-left interatrial shunt through a patent foramen ovale. Contrast transoesophageal echocardiography confirmed the right-to-left shunting. Considering the clinical symptoms were severe and refractory to medical treatment, she was referred for cardiac transplantation. Unfortunately the patient died suddenly a few weeks later.