Myocardial infarction associated with infective endocarditis: a case series.

INTRODUCTION: Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Its incidence ranges between 1% and 10%, but it has a high mortality rate. A high index of suspicion is required to diagnose it. Only case reports and small studies on this condition have been published; thus, it is unknown what the ideal treatment is. We review the challenges to diagnosing this disease and the most effective treatments for it. CASE PRESENTATION: We report a case series of three patients with acute coronary syndrome (ACS) in IE. The first patient presented with non-ST-elevation ACS. He underwent a stent placement for late-diagnosed embolic myocardial infarction, after which he was treated conservatively without valve replacement, with good results. The second patient with ST-elevation presented with ACS, for which conventional balloon angioplasty and successful double valve replacement were performed. ST-elevation ACS was also observed in the last patient, who experienced periannular complications, which necessitated surgery. DISCUSSION: Acute coronary syndrome is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate. Its management is complicated and cannot be standardized. Because each situation is unique, a multidisciplinary discussion is required to choose the best treatment.

Early aspirin desensitization in unstable patients with acute coronary syndrome: Short and long-term efficacy and safety.

BACKGROUND: Aspirin hypersensitivity is not a rare condition among patients with acute coronary syndrome. However, despite the publication of several successful desensitization protocols, the procedure is not as widespread as expected. We present a cohort of patients with acute coronary syndrome undergoing aspirin desensitization to evaluate its short- and long-term efficacy and safety and to reinforce data from previous studies. METHODS: Of 1306 patients admitted to our Coronary Care Unit between February 2011 and February 2013, 24 (1.8%) had a history of aspirin hypersensitivity. All 24 patients underwent an eight-dose aspirin desensitization protocol (0.1, 0.3, 1, 3, 10, 25, 50 and 100 mg of aspirin given by mouth every 15 minutes) after premedication with antihistamines and corticosteroids or antileucotrienes. Previously prescribed ß blockers and angiotensin-converting enzyme inhibitors were not discontinued. All patients were desensitized within 72 hours of admission. Those requiring urgent catheterization (five patients with ST segment elevation myocardial infarction) were desensitized within 12 hours of catheterization and the remainder before catheterization. RESULTS: All patients were successfully desensitized and only one presented with an urticarial reaction. The five patients with ST segment elevation myocardial infarction were treated with abciximab until desensitization was complete. All but one patient underwent catheterization and 20 underwent percutaneous coronary intervention, most (66%) with the implantation of a bare metal stent. At follow-up (a minimum of 6-24 months), only two patients had discontinued aspirin, both due to gastrointestinal bleeding, and no hypersensitivy reaction had occurred. CONCLUSIONS: Aspirin desensitization is effective and safe in unstable patients with acute coronary syndrome in both the short and long term.

[Transient ventricular dysfunction after emotional stress]. / Disfunción ventricular transitoria tras estrés emocional.

We describe a patient who developed severe ventricular dysfunction and cardiogenic shock after intense emotional stress. Her subsequent course was favorable, with complete recovery of left ventricular systolic function. The coronary arteries were normal and no specific etiologic agent was demonstrated. Her clinical picture was compatible with transient left ventricular apical ballooning. [I123]metaiodobenzyl guanidine cardiac scintigraphy showed a marked decrease in cardiac sympathetic nerve activity. We discuss the pathophysiologic mechanisms of this syndrome.

[Is heart transplantation for primary cardiac sarcoma a useful therapeutic option?]. / ¿Es útil el trasplante cardíaco como tratamiento del sarcoma cardíaco primario?

Primary cardiac sarcomas are rapidly progressive malignant tumors. No good therapeutic option is known. In recent years, heart transplantation has sometimes been performed in selected patients with cardiac sarcoma.We retrospectively analyzed 8 patients with primary cardiac sarcoma referred to our center to undergo assessment for heart transplantation. After an exhaustive study of the extension of the tumor, 6 patients were added to the waiting list for heart transplantation. Heart transplantation was not performed in 3 of these patients due to evidence of extracardiac extension, but the procedure was completed in the remaining 3 patients. The median survival in intention-to-treat analysis (transplantation or a frustrated transplantation attempt) was 8.5 months. Overall, the median survival of the 3 patients who underwent transplantation (12 months) was similar to that of the 5 patients who did not (11 months).

¿Es útil el trasplante cardíaco como tratamiento del sarcoma cardíaco primario? / Is heart transplantation for primary cardiac sarcoma a useful therapeutic option?

El sarcoma cardíaco primario es un tumor maligno de evolución rápida y fatal. Se desconoce en la actualidad cuál debe ser la aproximación terapéutica ideal a esta enfermedad. El trasplante cardíaco se ha utilizado ocasionalmente como tratamiento definitivo de esta entidad. Presentamos a 8 pacientes diagnosticados de sarcoma cardíaco primario que fueron valorados para trasplante. Después del estudio de extensión, 6 pacientes fueron incluidos en lista de espera para trasplante cardíaco. En 3 pacientes, la intervención no se pudo completar al demostrarse intraoperatoriamente la extensión extracardíaca del sarcoma, y en tres pacientes el procedimiento se llevó a término. La mediana de supervivencia por intención de tratar (trasplante o intento de trasplante) fue de 8,5 meses. La mediana de supervivencia de los 3 pacientes trasplantados (12 meses) fue similar a la de los 5 pacientes no trasplantados (11 meses) (AU)

[A case of transient left ventricular apical ballooning with an unusual complication]. / Síndrome de discinesia apical transitoria con una complicación inhabitual.

A retrospective study of patients with acute myocardial ischemia syndrome, mainly middle-aged and elderly women, was published in july 2001. The main features of acute myocardial ischemia were typical triggering circumstances, initial ECG mimicking acute myocardial infarction (AMI with transient appearance of Q waves and large negative T waves), mild or no enzymatic changes, and a combination of a normal coronary angiogram and transient left ventricular apical dyskinesia that normalized within days. The clinical course and prognosis were completely different from those of conventional AMI, with an increased number of acute-phase complications such as acute pulmonary edema, cardiogenic shock, and ventricular tachycardia. Despite this, the long-term outcome was better than that of AMI. We report a typical case diagnosed in a Spanish woman who developed embolic stroke, a complication not previously described, most likely related with her apical dyskinesia.

Síndrome de discinesia apical transitoria con una complicación inhabitual / A case of transient left ventricular apical ballooning with an unusual complication

En julio de 2001se ha publicado un estudio retrospectivo de pacientes, sobre todo mujeres de edad mediana y avanzada, que presentaban un síndrome de isquemia miocárdica aguda precedido de un desencadenante típico, con evolución inesperada en el electrocardiograma (aparición transitoria de ondas Q, ondas T negativas gigantes), leve o inexistente elevación enzimática y la combinación de coronarias normales y discinesia apical transitoria en la fase aguda, con normalización de la función ventricular días más tarde. El curso y el pronóstico son completamente diferentes de los del IAM convencional, con más complicaciones iniciales, como edema agudo pulmonar, shock cardiogénico y taquicardia ventricular y, sin embargo, mejor pronóstico a medio-largo plazos. Describimos un caso típico en una enferma de nuestro medio que presentó una embolia cerebral, complicación aún no descrita, probablemente relacionada con su discinesia apical (AU)