Effects of thrombolysis in the evolution of right bundle-branch block complicating an acute anterior myocardial infarction.

INTRODUCTION: There is scant information about the effects of thrombolysis in the evolution of right bundle-branch block (RBBB) in the setting of acute anterior myocardial infarction. The aim of this study has been to analyse these effects and its impact on prognosis. METHODS: We studied 54 patients who presented a RBBB related to an acute anterior myocardial infarction. We defined two groups: those who received thrombolytic treatment and those who did not. We analysed the evolution of RBBB (transience, moment of onset, moment of disappearance) and its relationship with in-hospital mortality.Twenty-one patients (39%) received thrombolytic treatment (groupT) and 33 patients (61%) (group NT) did not. RESULTS: The incidence of late appearance (> 6 h) of RBBB was less frequent in group T compared with group NT (10% vs. 33%, p = 0.04). The incidence of transient block was similar in the two groups (57% vs. 45%, p ns). However, early disappearance of RBBB (in < 6 hours) was more common in group T than in group NT (33% vs. 9%, p = 0.04). Mortality was higher in patients with RBBB present at 24 h after admission) than in those with RBBB resolved in less than 24 hours (in group NT, 55% vs. 8%, p = 0.02 and in group T 50% vs. 0%, p = 0.02, respectively). CONCLUSIONS: Thrombolysis seems to influence the moment of onset and disappearance of RBBB by promoting its early disappearance and avoiding its late appearance. Disappearance of RBBB is associated with a better prognosis.

[Massive pericardial effusion and cardiac tamponade as the presentation form of hypothyroidism]. / Derrame pericárdico masivo y taponamiento cardíaco como forma de presentación de hipotiroidismo.

We report a 43 years old female, admitted due to fatigability, asthenia and diffuse abdominal pain. On admission, obesity, slowness of thinking, bradycardia, distention of jugular veins and ascites were observed on physical examination. Laboratory showed undetectable thyroid hormone levels, a chest X ray showed bilateral pleural effusion and an enlarged heart. An echocardiography showed a massive pericardial effusion with collapse of the right atrium and dilatation of both caval veins. A pericardial tap was performed, draining 350 ml. Thyroid hormone substitution was started and after 12 months of follow up, the heart size decreased and a control echocardiogram showed a minimal pericardial effusion.

[The hemodynamic effects of the combination of milrinone in heart failure refractory to treatment with dopamine, dobutamine and/or nitroprusside]. / Efectos hemodinámicos de la asociación de milrinona en la insuficiencia cardíaca refractaria al tratamiento con dopamina, dobutamina y/o nitroprusiato.

INTRODUCTION: Classical treatment of advanced heart failure is mainly based on the intravenous administration of inotropic drugs and vasodilators. Phosphodiesterase-III inhibitors, drugs whose effectiveness is not affected for the beta-receptor downgrading, may be particularly helpful in patients with severe heart failure refractory to conventional treatment with dopamine, dobutamine and/or nitroprusside. PATIENTS AND METHODS: We have analysed the hemodynamic effects of milrinone in 13 patients (11 men, 2 women, mean age 55 +/- 12 years) with advanced heart failure resistant to dopamine, dobutamine and/or nitroprusside. Basally, before milrinone was administered, mean cardiac index and pulmonary capillary wedge pressure were 1.9 +/- 0.4 l/min/m2 and 25 +/- 6 mmHg, respectively. Milrinone was administered intravenously with a initial dose of 50 micrograms/kg over 10 minutes and followed by and infusion of 0.75 micrograms/kg/min over 6 hours. RESULTS: During milrinone administration cardiac index and stroke volume index significantly increased (40% and 28%, respectively) (p < 0.05). Furthermore, systemic and pulmonary vascular resistance indexes significantly decreased (17% and 30%, respectively) (p < 0.05). Mean right atrial pressure and pulmonary capillary wedge pressure also decreased (36% and 20%, respectively), but differences did not reach statistical significance. Milrinone was well tolerated and no patient presented serious side-effects. CONCLUSION: Our results suggest that in patients with advanced heart failure refractory to conventional treatment with dopamine, dobutamine and/or nitroprusside, the addition of milrinone significantly improves parameters of systolic function.

[Cardiac tamponade: clinical review of 53 cases]. / Taponamiento cardíaco: revisión clínica de 53 casos.

BACKGROUND: To describe the clinical features and prognosis of the patients with cardiac tamponade admitted in the coronary care unit. METHODS: Analysis the clinical data, etiology, treatment, and short term outcome of fifty three patients presenting with cardiac tamponade that required pericardiocentesis. RESULTS: Neoplasm (21 cases) and idiopathic pericarditis (10 cases) were the most frequent causes of cardiac tamponade. In forty four patients an haemorrhagic fluid was obtained. Neoplastic pericardial fluid showed a higher haematocrit than the rest (18 +/- 8% vs 7 +/- 5%, p less than 0.01). Recurrence of tamponade occurred in all but one neoplastic patients, and was early (less than 48 h) in 18 patients. Twenty seven patients underwent pericardiectomy, and recurrence was the most frequent indication (18 cases). Overall in-hospital mortality was 26%. Ten out of 14 deaths occurred in neoplastic patients and 2 deaths after myocardial perforation related to temporary pacemaker. No patient with idiopathic or post-pericardiotomy cardiac tamponade died. CONCLUSIONS: Short term outcome and prognosis in patients with cardiac tamponade mainly depends on the etiology. A high rate of early recurrence and death characterize the malignant cardiac tamponades.

[Pericardiocentesis: usefulness in the routine determination of intrapericardial pressure]. / Pericardiocentesis: utilidad de la determinación rutinaria de la presión intrapericárdica.

The usefulness of routine intrapericardial pressure determination and hemodynamic monitoring during therapeutic (n = 22) or diagnostic (n = 2) pericardiocentesis was analyzed. Hemodynamic data confirmed the presence of cardiac tamponade in all cases, including the 2 patients without clinical suspicion. Prior to fluid evacuation, abnormally elevated levels of intrapericardial (13 +/- 5 mmHg), right atrial (14 +/- 4 mmHg) and pulmonary capillary (16 +/- 3 mmHg) pressures were observed. A significant correlation was found between intrapericardial and right atrial pressures (r = 0.97, p less than 0.05) and also between intrapericardial and pulmonary capillary pressures (r = 0.69, p less than 0.05). The basal cardiac output was low (3 +/- 1 l/min) and increased after the pericardiocentesis in all but one patient. According to the results of pericardiocentesis, patients were classified into three groups. Group I: intrapericardial and right atrial pressures decreased to normal levels. The increment of cardiac output was high (72%) and the procedure was considered successful. Group II: right atrial and intrapericardial pressures remained elevated (7.7 +/- 4 and 7 +/- 2 mmHg, respectively) and the cardiac output increment was less marked (52%), thus indicating incomplete drainage. Group III: intrapericardial pressure decreased to normal levels but right atrial pressure remained elevated. All these patients were found to have associated cardiac disease, most frequently constriction. We conclude that routine determination of intrapericardial pressure: 1) reveals the presence of tamponade in cases without clinical suspicion; 2) indicates the efficacy of drainage; and 3) together with right atrial pressure recording, provides early diagnosis of associated cardiac disease, especially effusive-constrictive pericarditis.