Síntomas afectivos en pacientes con lesiones talámicas y su correlación con el patrón de conectividad talamocortical: revisión sistemática de la literatura / Affective symptoms in patients with thalamic lesions and their correlation with the thalamocortical connectivity pattern: a systematic review

RESUMEN Desde la década de 1970, la disponibilidad de neuroimágenes estructurales (tomografia computarizada y resonancia magnética) y funcionales como la tomografía computarizada por emisión de fotón único (SPECT), la tomografia por emisión de positrones (PET) o la resonancia magnética funcional (fMRI)), abrió una nueva via en el estudio de la relación bidireccional que existe entre los fenómenos comportamentales y la actividad neuronal. La introducción de estas técnicas condujo a una mejor comprensión del impacto de una lesión cerebral en la actividad cortical y en el desarrollo de síntomas psiquiátricos. Explicar la presencia de síntomas afectivos como una alteración en la función de una estructura cerebral es insuficiente, y se debe considerar siempre un compromiso de los circuitos cerebrales. Muchos trastornos del afecto se han asociado con lesiones en las conexiones talamolímbicas, incluyendo trastorno depresivo mayor, trastorno obsesivo-compulsivo, adicción a sustancias psicoactivas y trastorno de estrés postraumático, por lo que la identificación de los tractos de conectividad puede proporcionar nuevos medios para una intervención terapéutica eficaz.

SUMMARY Since the 1970s, the availability of structural neuroimaging (computed tomography and magnetic resonance imaging) and functional neuroimaging (single photon emission computed tomography (SPECT), positron emission tomography (PET), functional magnetic resonance imaging (fMRI)), has opened a new way in the study of the bidirectional relationship between behavioral phenomena and neuronal activity. The introduction of these techniques led to a better understanding of the impact of a brain injury on cortical activity and on the development of psychiatric symptoms. It is difficult to explain affective symptoms as a consequence of a brain structure dysfunction and is important to consider a brain circuit impairment. Many affective disorders have been associated with lesions in thalamolymbic connections, including major depressive disorder, obsessive-compulsive disorder, addiction to psychoactive substances and post-traumatic stress disorder, and the identification of the connectivity tracts can provide new means for effective therapeutic intervention.

Clinical impact of aortic regurgitation after transcatheter aortic valve replacement: insights into the degree and acuteness of presentation.

OBJECTIVES: The aim of this study was to determine the impact of the degree of residual aortic regurgitation (AR) and acuteness of presentation of AR after transcatheter aortic valve replacement (TAVR) on outcomes. BACKGROUND: The degree of residual AR after TAVR leading to excess mortality remains controversial, and little evidence exists on the impact of the acuteness of presentation of AR. METHODS: A total of 1,735 patients undergoing TAVR with balloon-expandable or self-expanding valves were included. The presence and degree of AR were evaluated by transthoracic echocardiography; acute AR was defined as an increase in AR severity of ≥1 degree compared with pre-procedural echocardiography. RESULTS: Residual AR was classified as mild in 761 patients (43.9%) and moderate to severe in 247 patients (14.2%). The presence of moderate to severe AR was an independent predictor of mortality at a mean follow-up of 21 ± 17 months compared with none to trace (adjusted hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.32 to 2.48; p < 0.001) and mild AR (adjusted HR: 1.68, 95% CI: 1.27 to 2.24; p < 0.001) groups. There was no increased risk in patients with mild AR compared with those with none to trace AR (p = 0.393). In patients with moderate to severe AR, acute AR was observed in 161 patients (65%) and chronic AR in 86 patients (35%). Acute moderate to severe AR was independently associated with increased risk of mortality compared with none/trace/mild AR (adjusted HR: 2.37, 95% CI: 1.53 to 3.66; p < 0.001) and chronic moderate to severe AR (adjusted HR: 2.24, 95% CI: 1.17 to 4.30; p = 0.015) [corrected]. No differences in survival rate were observed between patients with chronic moderate to severe and none/trace/mild AR (p > 0.50). CONCLUSIONS: AR occurred very frequently after TAVR, but an increased risk of mortality at ∼2-year follow-up was observed only in patients with acute moderate to severe AR.

Advanced chronic kidney disease in patients undergoing transcatheter aortic valve implantation: insights on clinical outcomes and prognostic markers from a large cohort of patients.

AIM: The aim of this study was to determine the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and to evaluate the predictive factors of poorer outcomes in such patients. METHODS AND RESULTS: This was a multicentre study including a total of 2075 consecutive patients who had undergone TAVI. Patients were grouped according the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 mL/min/1.73 m(2); n = 950), stage 3 (30-59 mL/min/1.73 m(2); n = 924), stage 4 (15-29 mL/min/1.73 m(2); n = 134) and stage 5 (<15 mL/min/1.73 m² or dialysis; n = 67). Clinical outcomes were evaluated at 30-days and at follow-up (median of 15 [6-29] months) and defined according to the VARC criteria. Advanced CKD (stage 4-5) was an independent predictor of 30-day major/life-threatening bleeding (P = 0.001) and mortality (P = 0.027), and late overall, cardiovascular and non-cardiovascular mortality (P < 0.01 for all). Pre-existing atrial fibrillation (HR: 2.29, 95% CI: 1.47-3.58, P = 0.001) and dialysis therapy (HR: 1.86, 95% CI: 1.17-2.97, P = 0.009) were the predictors of mortality in advanced CKD patients, with a mortality rate as high as 71% at 1-year follow-up in those patients with these 2 factors. Advanced CKD patients who had survived at 1-year follow-up exhibited both a significant improvement in NYHA class (P < 0.001) and no deterioration in valve hemodynamics (P = NS for changes in mean gradient and valve area over time). CONCLUSIONS: Advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI, with AF and dialysis therapy determining a higher risk in these patients. The mortality rate of patients with both factors was unacceptably high and this should be taken into account in the clinical decision-making process in this challenging group of patients.

Permanent pacemaker implantation after transcatheter aortic valve implantation: impact on late clinical outcomes and left ventricular function.

BACKGROUND: Very few data exist on the clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation. The objective of this study was to assess the impact of PPI after transcatheter aortic valve implantation on late outcomes in a large cohort of patients. METHODS AND RESULTS: A total of 1556 consecutive patients without prior PPI undergoing transcatheter aortic valve implantation were included. Of them, 239 patients (15.4%) required a PPI within the first 30 days after transcatheter aortic valve implantation. At a mean follow-up of 22±17 months, no association was observed between the need for 30-day PPI and all-cause mortality (hazard ratio, 0.98; 95% confidence interval, 0.74-1.30; P=0.871), cardiovascular mortality (hazard ratio, 0.81; 95% confidence interval, 0.56-1.17; P=0.270), and all-cause mortality or rehospitalization for heart failure (hazard ratio, 1.00; 95% confidence interval, 0.77-1.30; P=0.980). A lower rate of unexpected (sudden or unknown) death was observed in patients with PPI (hazard ratio, 0.31; 95% confidence interval, 0.11-0.85; P=0.023). Patients with new PPI showed a poorer evolution of left ventricular ejection fraction over time (P=0.017), and new PPI was an independent predictor of left ventricular ejection fraction decrease at the 6- to 12-month follow-up (estimated coefficient, -2.26; 95% confidence interval, -4.07 to -0.44; P=0.013; R(2)=0.121). CONCLUSIONS: The need for PPI was a frequent complication of transcatheter aortic valve implantation, but it was not associated with any increase in overall or cardiovascular death or rehospitalization for heart failure after a mean follow-up of ≈2 years. Indeed, 30-day PPI was a protective factor for the occurrence of unexpected (sudden or unknown) death. However, new PPI did have a negative effect on left ventricular function over time.

Demencia asociada con infección por VIH / HIV-Associated Dementia

Introducción: La demencia asociada con infección por VIH es la causa de demencia no traumática más frecuente en pacientes jóvenes. Objetivo: Señalar sus características clínicas, los métodos diagnósticos y el tratamiento de la demencia asociada con infección por VIH. Método: Revisión de la literatura médica publicada sobre el tema, utilizando las bases de datos Medline, Ovid y Hinari. Resultados: Las características clínicas en fases iniciales son hipoprosexia, bradipsiquia y apatía, que pueden simular depresión. En fases más avanzadas se presentan cambios cognoscitivos más específicos, como pérdida de memoria, cambios en la personalidad, asociados con insuficiencia motora y esfinteriana, como resultado de una mielopatía vacuolar. Conclusiones: Se deben realizar estudios complementarios para descartar otras causas de los cambios comportamentales y cognoscitivos. Las alteraciones vistas en resonancia magnética cerebral simple incluyen atrofia cortical y lesiones difusas de sustancia blanca. Las pruebas neuropsicológicas son útiles en el diagnóstico y, por lo general, muestran alteraciones en la velocidad psicomotora, atención, funciones del lóbulo frontal y memoria verbal y no verbal. La terapia HAART ha reducido de forma importante la incidencia de este tipo de demencia, que ahora afecta aproximadamente al 10% de los pacientes con sida en estadios avanzados.

Introduction: HIV-associated dementia is the most common nontraumatic dementia among young people. Objective: To describe the clinical features, diagnostic methods and treatment of HIV-associated dementia. Method: Review of the medical literature, available in Medline, Ovid and Hinari data bases. Results: The clinical features in the early stages may be mild with symptoms of poor concentration, mental slowing, and apathy which may mimic depression. Later on, as the syndrome progresses, more specific cognitive changes develop with memory loss and personality change associated with motor and sphincter difficulties as a result of an associated vacuolar myelopathy. Conclusions: Investigations are indicated to exclude other causes. MRI typically shows evidence of atrophy and diffuse white matter signal changes. Neuropsychological assessment typically shows abnormalities in the following cognitive domains: Psychomotor speed, attention, frontal lobe function, and verbal and non-verbalmemory. HAART has reduced its incidence and it now affects approximately 10% of patients with advanced disease.

Demencia frontotemporal / Frontotemporal Dementia

Introducción: el 20% de los pacientes que mueren con demencia antes de los 70 años de edad tienen demencia frontotemporal, un síndrome amplio con tres grandes variantes clínicas: variante frontal, demencia semántica y afasia primaria progresiva. Objetivo: presentar las características demográfi cas, la genética, el diagnóstico, la patología, el tratamiento y otras variantes de la demencia frontotemporal. Método: revisión de la literatura médica existente sobre el tema. Conclusión: la mayoría de las formas familiares de demencia frontotemporal tienen una herencia autosómica dominante y se asocian con mutaciones en el gen que codifi ca la proteína tau. Los síntomas iniciales están relacionados con cambios de personalidad, alteraciones comportamentales, del afecto, el lenguaje o las funciones ejecutivas, y se requieren imágenes cerebrales y pruebas neuropsicológicas para hacer un diagnóstico acertado. No existe en la actualidad tratamiento específi co para la demencia frontotemporal, y este se basa en el control de síntomas.

Introduction: Frontotemporal dementia constitutes a signifi cant percentage of the degenerative dementias, making up for 20% of patients who die with dementia before the age of 70. It is an extensive syndrome with three clinical variants: frontal variant, semantic dementia and primary progressive aphasia. Objective: To describe the demographic characteristics, genetics, diagnosis, pathology and treatment, as well as other types of frontotemporal dementia. Method: Review of the medical literature. Conclusions: Patients with this syndrome present with behavioral and affective symptoms, language diffi culties or executive dysfunction. An imaging study of the brain should be performed, as well as neuropsychological assessment. At present, no specifi c pharmacologic therapies have been approved for use in frontotemporal dementia.