Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor / Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy

La patología de la aorta siempre supone un reto para la medicina. Tanto para sudiagnóstico como para su tratamiento, dicha patología requiere ser abordada de forma multidisciplinar debido a la complejidad técnica y tecnológica de los medios empleados. Gracias a los esfuerzos durante años se están obteniendo frutos en forma de mejora de resultados, mediante un abordaje sistemático y protocolizado llevado acabo en el seno de un grupo de expertos (Comités de aorta o “Aortic team”) en el quese implican cardiólogos, cirujanos cardíacos, cirujanos vasculares, anestesiólogos y radiólogos, entre otros. Con este documento, realizado entre los grupos de trabajo de Aorta de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del dolor (SEDAR) y la Sociedad Española de Cirugía Torácica y Cardiovascular (SECTCV) se busca difundir protocolos de trabajo consensuados por ambas sociedades. La EACTS y la ESVS en el último documento de consenso de expertos definen el concepto de “AORTIC TEAM”(1). El equipo debe estar estrechamente involucrado en todo el proceso de diagnóstico, tratamiento y seguimiento y debe estar compuesto por miembros de cirugía cardiovascular en colaboración con anestesiología, cardiología, radiología y genética. Se recomienda la centralización de la atención de las patologías del arco aórtico en grandes centros porque es la única forma de comprender de manera efectiva el curso natural de la enfermedad, proporcionar toda la gama de opciones de tratamiento bajo un mismo prisma y tratar las posibles complicaciones. Debe estar disponible una vía simplificada de atención de emergencias (con disponibilidad 24h al día y 7 días a la semana), una adecuada capacidad de transporte y transferencia de pacientes, así como la posibilidad de una activación rápida del equipo multidisciplinar.(AU)

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving “Aortic teams” made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of “AORTIC TEAM”(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.(AU)

Usefulness of severity scales for cardiogenic shock in-hospital mortality. Proposal for a new prognostic model.

Cardiogenic shock (CS) is a condition comprising multiple etiologies, which associates high mortality rates. Some scoring systems have been shown to be good predictors of hospital mortality in patients admitted to Critical Care Units (CCU). The main objective of this study is to analyze their usefulness and validity in a cohort of CS patients. METHODS: Observational unicentric study of a cohort of CS patients. SOFA, SAPS II and APACHE II scores were calculated in the first 24 h of CCU admission. RESULTS: 130 patients with CS were included. SOFA, SAPS II and APACHE II scores revealed good discrimination for hospital mortality: (AUC) ROC values (AUC: 0.711, 0.752 and 0.742 respectively; P = .6). Calibration, estimated by the Hosmer-Lemeshow test, was adequate in all cases. Acute coronary syndrome, lactate serum values, SAPS II score and vasoactive inotropic score (VIS) were found to be independent predictors for mortality, upon ICU admission. With these variables, a specific prognostic indicator was developed (SAPS-2-LIVE), which improved predictive capability for mortality in our series (AUC) ROC, 0.825 (95% CI 0.752-0.89). CONCLUSION: In this contemporary CS cohort, the aforementioned scores have been shown to have good predictive ability for hospital mortality. These findings could contribute to a more accurate risk stratification in CS.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy. / Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery. / Guía anestésico-quirúrgica en el tratamiento de la patología de aorta toracoabdominal. Documento de Consenso de la Sociedad Española de Cirugía Cardiovascular Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

Validation study of a new dry self-sampling device for detection of human papilloma virus in cervical cancer screening / Estudio de validación de un nuevo dispositivo de automuestreo en seco para la detección del virus del papiloma humano en el cribado del cáncer cervical

Objective: To evaluate the efficiency of IUNETEST(R) self-sampling device by comparing f-HPVtypingTM and Cobas(R) 4800 HPV detection techniques in gynecological cytology and self-sampling up-take. Material and methods: A total of 196 patients were included: Fifty percent (50%) for routine cervical cancer screening (n=98) and the other half presented an abnormal cytology (n=98). Two samples for patient were evaluated. Results: Both sample up-takes showed high concordance for HPV detection (Cohen's kappa > 0.85). Equal sensitivity between molecular techniques was detected in Gynecological cytology up-takes (77.3%). In self-sampling, sensiti-vity was higher in f-HPVtypingTM than in Cobas(R) 4800 (77.3% vs. 75.5%). Roche presented better specificity thanf-HPVtypingTM: 82.3 and 80.7% vs. 79.2 and 78.5% in self-sample and gynecological up-takes. Negative predictive value was similar: 87.3 and 87.7% vs. 87.2 and 86.7% in self-sample and gynecological up-take by Roche and in f-HPVtyping, respectively. The most prevalent types were HPV-16, followed by 52, 39, 58 and 66. Conclusions: Self-sample up-takes may be as good as physician collected samples for screening diagnostic. Both HPV detection methods present a high correlation for both sample collections. The high acceptability of IUNETEST(R) self-sample device, may encourage screening in non-attenders, increasing screening coverage

Objetivo: evaluar la eficiencia del dispositivo de autotoma IUNETEST(R) comparando las técnicas de detección de HPV, f-HPVtypingTM y Cobas(R) 4800 en la citología ginecológica y la toma de auto-muestreo. Material y métodos: se incluyeron un total de 196 pacientes: cincuenta por ciento (50%) para la detección de cáncer de cuello uterino de rutina (n=98) y la otra mitad presentaba una citología anormal (n=98). Se evaluaron dos muestras por paciente. Resultados: ambas tomas de muestras mostraron una alta concordancia para la detección del VPH (kappa de Cohen> 0,85). Igual sensibilidad entre las técnicas moleculares se detectó en tomas de citología ginecológica (77,3%). En el auto-muestreo, la sensibilidad fue mayor en f-HPVtypingTM que en Cobas(R) 4800 (77,3% vs. 75,5%). Roche presentó una mejor especificidad que f-HPVtypingTM: 82,3 y 80,7% vs. 79,2 y 78,5% en muestras de autotoma y ginecológicas. El valor predictivo negativo fue similar: 87,3 y 87,7% vs. 87,2 y 86,7% en la autotoma y la captación ginecológica de Roche y en f-HPVtyping, respectivamente. Los tipos más prevalentes fueron HPV-16, seguido de 52, 39, 58 y 66. Conclusiones: Las tomas de muestras por autotoma pueden ser tan buenas como las muestras recolectadas por el médico para el diagnóstico de detección del HPV. Ambos métodos de detección de HPV presentan una alta correlación para ambas colecciones de muestras. La alta aceptabilidad del dispositivo de auto-muestra IUNETEST(R) puede alentar la detección en personas que no asisten, aumentando la cobertura del screening

Dual-time-point 18F-FDG-PET/CT imaging of a paravalvular pseudoaneurysm after infective endocarditis / Imagen PET/TC de doble fase con 18F-FDG de un seudoaneurisma paravalvular tras endocarditis infecciosa

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Elevated expression levels of lysyl oxidases protect against aortic aneurysm progression in Marfan syndrome.

Patients with Marfan syndrome (MFS) are at high risk of life-threatening aortic dissections. The condition is caused by mutations in the gene encoding fibrillin-1, an essential component in the formation of elastic fibers. While experimental findings in animal models of the disease have shown the involvement of transforming growth factor-ß (TGF-ß)- and angiotensin II-dependent pathways, alterations in the vascular extracellular matrix (ECM) may also play a role in the onset and progression of the aortic disease. Lysyl oxidases (LOX) are extracellular enzymes, which initiates the formation of covalent cross-linking of collagens and elastin, thereby contributing to the maturation of the ECM. Here we have explored the role of LOX in the formation of aortic aneurysms in MFS. We show that aortic tissue from MFS patients and MFS mouse model (Fbn1(C1039G/+)) displayed enhanced expression of the members of the LOX family, LOX and LOX-like 1 (LOXL1), and this is associated with the formation of mature collagen fibers. Administration of a LOX inhibitor for 8weeks blocked collagen accumulation and aggravated elastic fiber impairment, and these effects correlated with the induction of a strong and rapidly progressing aortic dilatation, and with premature death in the more severe MFS mouse model, Fbn1(mgR/mgR), without any significant effect on wild type animals. This detrimental effect occurred preferentially in the ascending portion of the aorta, with little or no involvement of the aortic root, and was associated to an overactivation of both canonical and non-canonical TGF-ß signaling pathways. The blockade of angiotensin II type I receptor with losartan restored TGF-ß signaling activation, normalized elastic fiber impairment and prevented the aortic dilatation induced by LOX inhibition in Fbn1(C1039G/+) mice. Our data indicate that LOX enzymes and LOX-mediated collagen accumulation play a critical protective role in aneurysm formation in MFS.

Accuracy of noninvasive estimation of pulmonary wedge pressure by echocardiographic indices in heart transplant recipients.

BACKGROUND: Pulmonary capillary wedge pressure (PCWP) can be estimated from transmitral or color M-mode Doppler flow propagation velocities. However, it has been recommended to not use these indices in heart transplant recipients. Our aim was to compare the accuracy of color M-mode, Doppler, and Doppler tissue imaging (DTI)-derived indices to predict PCWP in heart transplant recipients. METHODS: We studied 50 consecutive heart transplant recipients scheduled for routine right-sided heart catheterization and endomyocardial biopsy. Their mean age was 49 ± 17 years and the mean time after heart transplantation was 29 ± 41 months. An echocardiogram was performed immediately after the invasive procedure. We analysed PCWP, transmitral flow velocity variables (peak velocity during early filling (E) and deceleration time [DT]), color M-mode Doppler flow propagation velocity (Vp), and mitral annulus peak early diastolic velocity (E') from DTI. Doppler estimated-PCWP (ePCWP) was calculated as follows: (5.27 × E/Vp) + 4.6. RESULTS: Mean ejection fraction was 66 ± 11%. The mean invasive measured PCWP was 11.14 ± 5.4 mm Hg and the mean noninvasive ePCWP was 11.13 ± 1.8 mm Hg (r = 0.66; P < .0001). A good correlation was present between invasive PCWP and mitral PW-Doppler and DTI parameters: peak E 91 ± 22 cm/s (r = 0.34; P = .02) and DT 143 ± 26 s (r = -0.436; P = .002), E/E' ratio medial mitral annulus 10 ± 4 cm/s (r = 0.353; P = .026) and E/E' ratio lateral mitral annulus 6 ± 2 cm/s (r = 0.462; P = .002). E/Vp was the most accurate index for predicting PCWP (r = 0.615; P < .0001). CONCLUSIONS: Compared with other indirect Doppler indices, E/Vp showed the best correlation to predict PCWP in heart transplant recipients. Despite previous recommendations, PCWP can be accurately estimated from color M-mode indices, giving useful information and avoiding the risks of invasive measurements.

Recomendaciones sobre ranelato de estroncio en el tratamiento de la osteoporosis / Recommendations on strontium ranelate in the treatment of osteoporosis

Actualmente disponemos de diversas intervenciones que pueden reducir la incidencia de fracturas osteoporóticas, como son medidas higiénico-dietéticas, reducir el riesgo de caídas y tratamientos farmacológicos específicos. El ranelato de estroncio es el único fármaco antiosteoporótico con un mecanismo de acción dual, ya que inhibe la resorción a la vez que estimula la formación ósea. Los estudios realizados demuestran su capacidad para mejorar los parámetros de calidad ósea (microarquitectura), aumentar la densidad mineral ósea y reducir el riesgo de fracturas vertebrales y no vertebrales. Ha demostrado eficacia en mujeres osteopénicas y osteoporóticas, tanto con fracturas como sin ellas, y tanto en los primeros años después de la menopausia como en las mujeres mayores. Existen datos de seguridad a 10 años en condiciones reales de administración, demostrando tener un adecuado perfil de seguridad y tolerancia. El ranelato de estroncio, debido a su eficacia, seguridad y años de experiencia, es un tratamiento de primera elección para las mujeres con osteoporosis posmenopáusica y riesgo de fractura (AU)

At present, several interventions are available to reduce the incidence of osteoporotic fractures, such as lifestyle modifications, reducing the risk of falls and specific pharmacological treatments. Strontium ranelate is the only anti-osteoporotic drug with a dual mechanism of action, since it inhibits bone resorption while stimulating bone formation. The studies performed to date have shown the ability of this drug to improve bone quality parameters (microarchitecture), increase bone mineral density and reduce the risk of vertebral and nonvertebral fractures. Strontium ranelate has demonstrated efficacy in osteopenic and osteoporotic women, with or without fractures, in the first few years after menopause and in older women. Safety data are available for 10 years and under real conditions of administration, and demonstrate an adequate safety profile and tolerance. Due to its efficacy, safety and years of use, strontium ranelate is a first choice treatment for women with postmenopausal osteoporosis and fracture risk (AU)

Mechanisms of ischemic stroke in HIV-infected patients.

OBJECTIVE: To evaluate the types and mechanisms of stroke in a large population of HIV-infected patients. METHODS: We reviewed records of consecutive HIV-infected patients with acute stroke admitted to a large metropolitan hospital between 1996 and 2004. Stroke mechanism was defined by consensus between two cerebrovascular neurologists using TOAST classification. RESULTS: A total of 82 patients were included, 77 with ischemic stroke and 5 with intracerebral hemorrhage. Mean age was 42 years and 89% were African American. Previous diagnosis of HIV infection was documented in 91% and AIDS diagnosis in 80%. Mean CD4 count was 113 cells/mm(3) and 85% had CD4 count <200 cells/mm(3). A total of 61% of patients had received combination antiretroviral treatment (CART). The mechanism of ischemic stroke was large artery atherosclerosis in 12%, cardiac embolism in 18%, small vessel occlusion in 18%, other determined etiology in 23%, and undetermined in 29% (including 19% with incomplete evaluation). Vasculitis was deemed responsible for the stroke in 10 patients (13%) and hypercoagulability in 7 (9%). Protein S deficiency was noted in 10/22 (45%) and anticardiolipin antibodies in 9/31 (29%) tested patients. When comparing patients with large or small vessel disease (atherothrombotic strokes) vs the rest of the population, there were no differences in exposure to CART or CD4 count, but patients with non-atherothrombotic strokes were younger (p = 0.04). Recent cocaine exposure was less common among patients with atherothrombotic strokes (p = 0.02). Strokes were fatal or severely disabling in 35% of cases. CONCLUSIONS: Stroke mechanisms are variable in HIV-infected patients, with a relatively high incidence of vasculitis and hypercoagulability. In our population of severely immunodepressed patients, exposure to combination antiretroviral treatment did not significantly influence the mechanism of stroke.

Melanoma maligno coroideo y metástasis hepáticas tardías / Choroids melanoma and liver metastasis

Se presenta un caso de melanoma maligno de coroides que tras el tratamiento quirúrgico por el servicio de Oftalmología y seguido ambulatoriamente, es visto a los 11 años por presentar molestias difusas abdominales y alteración desde hacia unos 5 años solamente de elevación de las transaminasas (GOT y GPT). Exploración oftalmológica negativa pero por ecografía y TAC evidencia de una metástasis en cada lóbulo hepático, decidiéndose intervención quirúrgica y encontrándose múltiples metástasis bilobulares, falleciendo el paciente por fallo hepático a los 6 meses de la intervención. Se revisan las técnicas diagnósticas, anatomía patológica, tratamiento quirúrgico y oncológico de dicha localización, así como el de las metástasis a distancia (AU)

We present the case of a patient with a malignant choroid melanoma that eleven years after surgical treatment by the Ophthalmology Department, presented a diffuse abdominal pain of five years evolution with elevation of transaminases (SGOT and SGPT). The ophtalmological exploration was normal but the abdominal echography and computerized axial tomography showed a metastasis in each lobe of the liver. It was decided surgical treatment and multiple metastasis were founded. The patient died after six months because of a liver failure. The diagnostic procedures, pathologic anatomy and surgical and oncological treatment of this local disease and its metastasis are reviewed (AU)

The importance of preventive health care in post-menopausal women.

Women make up 55% of the total world population. This percentage is set to steadily increase over the next three decades. Europe also has the highest proportion of older women in the world. In fact, there are now approximately 3 women for every 2 men over 65. All of this data confirms the importance of prevention. An ideal approach for the female post-menopausal population would be treatment of any condition that can improve physical, mental and social well-being. Nevertheless, it is understood that the efficacy and cost/benefits of every screening programme need to be analysed. One of the largest and most neglected groups that could benefit from prevention consists of women without hot flushes (asymptomatic women), but with risk factors. The strategic measures are information, research and development of programmes. The more practical approach would be to identify patients and therefore yield better results in terms of health status and improvement. Statistics show that the three main causes of mortality and disability in developed countries for post-menopausal women are cardiovascular disease (CVD), cancer and osteoporosis-associated fractures. There are agreed recommendations to include some preventive measures for these three disorders in clinical practice for health professionals, at least at the minimal level. Research into the role that other diseases play will allow strategies to be developed in order to enhance prevention. Disorders such as urinary incontinence, dyspareunia, visual and hearing impairment and cognitive dysfunction are seen in significant percentages in post-menopausal women and may affect their quality of life. Health care professionals should bear in mind that many women may be reluctant to raise questions about some disorders spontaneously. Physicians should therefore search for patients with risk factors for these diseases. Prevention and treatment to avoid medical accidents will improve the quantity and quality of life.

Surgical treatment of nonbacterial thrombotic endocarditis presenting with stroke.

BACKGROUND: Necropsy studies have shown that nonbacterial thrombotic endocarditis (NBTE) may be associated with cerebral infarctions and antemortem diagnosis is now possible. However, the best treatment for patients with NBTE presenting with stroke is not known. We describe three patients presenting with an acute embolic stroke secondary to large,mobile vegetations detected by transthoracic (one case) or transesophageal echocardiography (two cases). All patients underwent surgery for removal of the vegetations to prevent recurrent embolic events; valve replacement was necessary in two cases. The sterile nature of the vegetations was confirmed by pathological examination and negative stains and cultures of the surgical samples. A previously unrecognized hypercoagulable condition was diagnosed in all patients (antiphospholipid antibody syndrome in two cases and disseminated adenocarcinoma in one case). CONCLUSION: NBTE should be considered among the possible causes of embolic stroke even in the absence of history of cancer, hypercoagulability, or previous embolic manifestations. If NBTE is diagnosed, the possibility of underlying thrombophilia should be thoroughly investigated. Valvular surgery represents a valuable therapeutic alternative in patients with large mobile vegetations, valvular dysfunction or recurrent embolic events despite anticoagulation.

Hydatid disease of the interventricular septum causing pericardial effusion.

Echinococcal infestation of the heart is uncommon. We report a case of a 35-year-old man with an hydatid cyst located in distal interventricular septum. Clinical presentation was chest pain and urticaria. Diagnosis was made by echocardiography and magnetic resonance imaging. Surgical resection was performed; the cyst was punctured and its content was drained, hypertonic glucose solution was instilled for sterilization, and it was removed. The patient did well and remains asymptomatic. Diagnosis and ultimate surgical treatment of this disease prevented potentially lethal complications such as cyst rupture with embolic phenomena and anaphylactic shock.

Diffusion-weighted imaging shows cytotoxic and vasogenic edema in eclampsia.

In eclampsia, MR imaging shows reversible T2 hyperintensities in a parietal and occipital distribution. Findings on diffusion-weighted images suggest that these abnormalities are areas of vasogenic edema. We describe the presence of both cytotoxic and vasogenic edema, as detected by diffusion-weighted imaging, in a woman with eclampsia. Follow-up MR imaging showed that the regions of cytotoxic edema progressed to cerebral infarction. This case suggests that diffusion-weighted imaging allows the early detection of ischemic infarcts in patients with eclampsia.

[Angioplasty and stenting in carotid stenosis. Therapeutic alternative or technical possibility?]. / Angioplastia y stenting de la estenosis carotídea. Alternativa terapéutica o posibilidad técnica?

OBJECTIVE: Review the current knowledge on the use of angioplasty and stenting (A/S) for the treatment of carotid stenosis with emphasis on proposed indications. DEVELOPMENT: The standard treatment for carotid stenosis is carotid endarterectomy (CE). However, excessive surgical risk and/or technical difficulty occasionally impose limitations on the surgical approach. Therefore, the option of percutaneous treatment with A/S becomes an appealing alternative. A/S techniques are constantly improved but there is very little prospective data supporting its value at present. The reported complication rates appear comparable to those of CE. Indications for A/S of the carotid artery are not fully delineated yet. We believe that adequate candidates for carotid A/S must have symptomatic high-degree carotid stenosis and at least one of the following situations: unstable coronary disease, severe systemic disease, surgically inaccessible carotid lesion (including some cases of carotid stenosis secondary to neck radiation), contralateral carotid occlusion, or recurrent stenosis after prior CE. CONCLUSIONS: A/S represents a promising alternative to CE in the treatment of carotid stenosis. However, in the absence of prospective comparative trials, A/S should be currently reserved exclusively for those patients in whom surgery is prohibited by very high surgical risk or technical inaccessibility. A/S of the carotid artery should only be performed by operators with ample expertise in the field.