Bloqueo del ganglio estrellado como tratamiento de la tormenta arrítmica: estudio observacional / Stellate ganglion block as a treatment for arrhythmic storm: an observational study

Introducción: La tormenta arrítmica (TA) es una situación de emergencia potencialmente letal, con una elevada tasa de mortalidad. Cuando el tratamiento convencional agudo es inefectivo, el bloqueo del ganglio estrellado puede ayudar a controlar la arritmia, aportando un bloqueo simpático cervicotorácico visceral. El objetivo de este estudio es valorar la efectividad y seguridad de los bloqueos del ganglio estrellado (BGE) para el tratamiento de la TA refractaria. Método: Seguimiento de una cohorte de pacientes con TA refractaria que cumplieron los criterios para la realización de BGE. Dicho bloqueo fue ecoguiado al nivel de C6, utilizando un anestésico y un esteroide, de manera unilateral izquierda en primer lugar, y bilateral de no existir respuesta, realizándose posteriormente ablación mediante radiofrecuencia (RFC) guiada por fluoroscopio en C7 de no existir respuesta favorable, sino recidiva subsiguiente. Resultados: Se incluyeron siete pacientes, con una tasa de mortalidad durante el ingreso de 14,29%. Cuatro pacientes recibieron bloqueos unilaterales del ganglio estrellado, y en tres pacientes se realizaron bloqueos bilaterales. En seis de ellos se aplicó ablación, y uno de ellos tenía implantado un cardioversor-desfibrilador. La TA fue controlada temporalmente, más allá del efecto del anestésico local en todos los pacientes. Tres de ellos recibieron ablación por RFC, y dos simpatectomías torácicas quirúrgicas. El único efecto secundario fue el síndrome de Horner, que se observó en todos los casos tras realizar el bloqueo del ganglio estrellado con anestésico local. Dos pacientes murieron tras recibir el alta, y cuatro siguen en sus casas, tres de ellos sin haber sido ingresados a causa de episodios ventriculares durante más de dos años. Conclusión: El bloqueo ecoguiado del ganglio estrellado es una técnica efectiva y segura para el tratamiento de la TA refractaria, como complemento del tratamiento cardiológico habitual.(AU)

Introduction: Arrhythmic storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, a stellate ganglion block can contribute to the control of the arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of the study is to assess the effectiveness and safety of stellate ganglion blocks for the treatment of refractory arrhythmic storm. Method: Follow-up of a cohort of patients with refractory arrhythmic storm that met the criteria for performing stellate ganglion blocks. The block was ultrasound-guided at C6-level using local anaesthetic and a steroid, left unilateral first, bilateral if no response, and followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. Results: Seven patients were included, with a mortality rate during admission of 14.29%. Four patients received unilateral and three bilateral stellate ganglion blocks. Six were ablated and one of them had an implanted cardioverter-defibrillator. Arrhythmic storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three underwent radiofrequency ablation and two underwent surgical thoracic sympathectomy. The only side effect was Horner's syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two died after discharge and four are still at home, three of them without further admission due to ventricular events for more than two years. Conclusion: An ultrasound-guided stellate ganglion block is an effective and safe technique in the treatment of refractory arrhythmic storm as a complement to the usual cardiological treatment.(AU)

Stellate ganglion block for the management of electrical storm: An observational study.

INTRODUCTION: Electrical storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, stellate ganglion block can help control arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of this study is to assess the effectiveness and safety of stellate ganglion block in the management of refractory arrhythmic storm. METHOD: Follow-up of a cohort of patients with refractory electrical storm that met the criteria for performing stellate ganglion block. The block was ultrasound-guided at C6 using local anaesthetic and a steroid - left unilateral first, bilateral if no response, followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. RESULTS: Seven patients were included. The in-hospital mortality rate was 14.29%. Four patients received unilateral and 3 bilateral stellate ganglion block. Six were ablated and 1 received an implantable cardioverter-defibrillator. Electrical storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three patients underwent radiofrequency ablation and 2 underwent surgical thoracic sympathectomy. The only side effect was Horner's syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two patients died after discharge and 4 are alive at the time of writing, 3 of them have not been re-admitted for ventricular events for more than 2 years. CONCLUSION: Ultrasound-guided stellate ganglion block is an effective and safe complement to standard cardiological treatment of refractory electrical storm.

The tobacco paradox in acute coronary syndrome. The prior cessation of smoking as a marker of a better short-term prognosis. / La paradoja del tabaco en el síndrome coronario agudo. El abandono previo del hábito tabáquico como marcador de mejor pronóstico a corto plazo.

OBJECTIVE: The tobacco paradox is a phenomenon insufficiently explained by previous studies. This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome. METHODS: We obtained data from the ARIAM registry, between 2001 and 2012. The study included 42,827 patients with acute coronary syndrome (mean age, 65±13 years; 26.4% women). The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis. RESULTS: The smokers were younger, were more often men, had less diabetes, hypertension and prior history of heart failure, stroke, arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking. The ex-smokers had more dyslipidaemia and history of angina, myocardial infarction, ischemic heart disease, peripheral vasculopathy and chronic bronchial disease. Smokers and ex-smokers less frequently developed cardiogenic shock (smokers 4.2%, ex-smokers 4.7% and nonsmokers 6.9%, P<.001). Hospital mortality was 7.8% for the nonsmokers, 4.9% for the ex-smokers and 3.1% for the smokers (P<.001). In the multivariate analysis, the smoker factor lost its influence in the prognosis (-0.26%, p=.52 using an inverse probability calculation; and+0.26%, P=.691 using a propensity analysis). However, the exsmoker factor showed a significant reduction in mortality in both tests (-2.4% in the inverse probability analysis, P<.001; and -1.5% in the propensity analysis, P=.005). CONCLUSIONS: The tobacco paradox is a finding that could be explained by other prognostic factors. Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis.

Taquicardia ventricular en paciente joven / Ventricular tachycardia in a young patient

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Long term outcome of patients with postinfarction left ventricular pseudoaneurysm.

BACKGROUND: It is debatable whether surgical repair is routinely indicated in asymptomatic patients with left ventricular pseudoaneurysms. OBJECTIVE: To evaluate the long term outcome of patients with pseudoaneurysm after myocardial infarction, focusing on those treated conservatively. METHODS: 10 patients with postinfarction left ventricular pseudoaneurysm were followed up over a mean (SD) period of 3.8 (5.2) years. RESULTS: In those treated conservatively (n = 9), cumulative survival was 88.9 (10.5)% and 74.1 (16.1)% at one and four years, respectively. The probability of being free of cardiac death was 88.9 (10.5)% at both one and four years. No patient had complete fatal heart rupture during follow up. Three patients suffered ischaemic stroke (at 1, 11, and 62 months). The cumulative incidence of ischaemic stroke was 10% at one year and 32.5% at four years. CONCLUSIONS: Long term outcome of patients with postinfarction left ventricular pseudoaneurysm is relatively benign, with a very low risk (none in this series) of fatal rupture. Taking into consideration the relatively high risk of stroke, chronic anticoagulant treatment could be considered.

Tabaco y enfermedad coronaria / Tobacco and coronary artery disease

El tabaco actúa sinérgicamente con otros factores de riesgo, aumentando sustancialmente el riesgo de enfermedad coronaria, y siguen apareciendo nuevas evidencias de esta relación. Los beneficios de dejar el tabaco se dan incluso en las personas que ya han desarrollado enfermedad coronaria. Cualquier esfuerzo dirigido contra el hábito de fumar merece la pena. La terapia sustitutiva de nicotina se ha mostrado eficaz, y debería estar disponible en los programas de abandono del tabaco. Recientes estudios han mostrado cómo una intervención estatal agresiva lleva a una reducción de muertes por enfermedad coronaria a corto plazo. (AU)

Hipertrofia ventricular izquierda medioventricular y aneurisma apical del ventrículo izquierdo: ¿un síndrome con entidad propia? / Left midventricular hypertrophy and apival aneurysm of the left ventricle: a syndrome with real entity?

Una paciente de 67 años ingresa en nuestro hospital por infarto agudo de miocardio inferior. La ventriculografía izquierda reveló la presencia de una obliteración sistólica medioventricular importante y un aneurisma en el ápex del ventrículo izquierdo (VI), y la coronariografía una estenosis ligera de la arteria coronaria derecha. La coexistencia de hipertrofia ventricular izquierda medioventricular y un aneurisma apical del VI es extraordinariamente infrecuente. Se revisa la literatura y los posibles mecanismos etiopatogénicaos de esta asociación anatomoclínica (AU)

[Intrapericardial cisplatin for malignant tamponade]. / Cisplatino intrapericárdico en el taponamiento neoplásico.

The choice therapy of malignant pericardial effusion is controversial. Pericardiocentesis is usually successful in alleviating tamponade, but unfortunately, that tamponade recurs frequently and patients are then again exposed to a critical situation and need hospitalization. Several different approaches have been advocated in order to prevent reaccumulation of the pericardial fluid, most of them quite cumbersome. We present our experience with intrapericardial administration of cisplatin. There were 6 patients, and the primary tumor was breast carcinoma in 2, lung in 1, ovary in 1, mediastinal fibrosarcoma in 1, and unknown in 1. Administration of cisplatin was virtually uneventful and painless, and there were no recurrences, with a survival of 2 to 18 months (mean 5.6).We conclude that intrapericardial cisplatin is safe and effective in treating malignant pericardial tamponade and preventing recurrence.

El tabaco y sus efectos sobre el sistema cardiovascular / Smoking and its effects on the cardiovascular system

El tabaco es responsable de una parte significativa de la enfermedad y la mortalidad cardiovascular en los países occidentales. Hay numerosos mecanismos que explican este efecto deletéreo: el tabaco crea un perfil lipídico desfavorable, promueve la agregación y la coagulación, induce vasoconstricción y disfunción endotelial, acelera la aterosclerosis, aumenta el tono simpático, y todos estos mecanismos se han demostrado también en el tabaquismo pasivo. Al fumar, las mujeres pierden su 'protección natural' contra la enfermedad cardiovascular.Las formas alternativas de tabaco no ofrecen protección, pues tanto los cigarrillos bajos en nicotina como los cigarros puros han demostrado ser factores de riesgo significativos. Por el contrario, dejar el tabaco es una medida muy protectora, tanto en prevención primaria como secundaria. Es bastante sencillo aconsejar que se deje el tabaco, y ningún fumador debe abandonar nuestra consulta sin oir unas palabras al respecto. Hay al menos dos medidas farmacológicas útiles: los parches de nicotina y el bupropio. Cualquier esfuerzo en promover el abandono del hábito de fumar merece la pena (AU)

Total occlusion of the left main coronary artery in a young cocaine user.

A young woman, currently user of cocaine, was admitted because of acute myocardial infarction with cardiogenic shock. The coronary arteriography revealed total occlusion of the left main coronary artery. Despite the use of an intraaortic counterpulsation balloon and successful percutaneous transluminal coronary angioplasty, she developed electromechanical dissociation, unresponsive to resuscitation manoeuvres.

Transmyocardial revascularization with holmium laser.

Sixteen patients with angina refractory to medical therapy who were not considered suitable for standard revascularization underwent transmyocardial revascularization with holmium laser. The average age of the patients was 63.2 +/- 10.5 years. All of them had angina class 3 or 4, and 9 (56%) had previously undergone an aortocoronary bypass grafting. Four patients died during the 6-month follow-up period (25%). Among the survivors, anginal class decreased to class 2 or 1 at the 6th month (p = 0.002). Ejection fraction did not change. The ischemic burden by Holter decreased from 85.3 +/- 656 to 5.5 +/- 9.7 min (p = 0.046). Myocardial perfusion with 201Tl single photon emission computed tomography (SPECT) images at rest and after dipyridamole showed a significant improvement among the ischemic treated segments (p = 0.015). Baseline ejection fraction was somehow lower in nonresponsive than in responsive patients (33 +/- 13 vs. 49 +/- 10, p = 0.052). We conclude that transmyocardial laser revascularization with holmium laser is effective in treatment in ischemic patients not amenable to surgery or percutaneous procedures, as previously reported with CO2 laser. Further investigation is needed to determine which clinical profiles identify the patients for whom this therapy is suitable.

[Influence of coronary risk factors in secondary prevention: tobacco]. / Influencia de los factores de riesgo coronario en prevención secundaria: tabaco.

Tobacco smoking is a strong independent factor for atherosclerotic disease, equivalent to hypertension or high cholesterol levels. Middle age people are especially involved, with a mortality rate of about 20% as a consequence of smoking, and a mean loss of life expectancy of 20 years. There is a positive correlation between smoking and severity of atherosclerotic disease in the coronary and cerebral arteries, and the aorta. It has been shown that smoking cessation clearly enhances the prognosis of patients with myocardial infarction. Twice a increase in mortality rate has been found among nonstopping smokers compared with those who stopped smoking eight years after myocardial infarction. In addition, progression of atherosclerosis as shown by angiography is slowed by stopping to smoke. As the coronary risk factors act in a synergistic way, a comprehensive approach to the patient is recommended, especially in smokers with myocardial infarction. It is justified an intensive intervention because of the advantages in this population. The physician should clearly communicate to the patient the need of stopping to smoke, which carries sometimes as beneficial effects as other interventions. A wise use of replacement therapy with transdermal nicotine, together with other useful measures, allows us to manage patients with a broad margin of safety, especially in coronary patients, who win most benefit from ceasing to smoke.

Abnormal filling pattern of the left ventricle and outcome in acute myocardial infarction.

BACKGROUND: The pattern of left ventricular filling by Doppler examination is frequently abnormal in myocardial infarction. PURPOSE: To relate the different patterns of left ventricular filling to the clinical course of acute myocardial infarction. PATIENTS AND METHODS: We have studied 133 patients with acute myocardial infarction. Three different patterns of mitral flow were defined by Doppler examination: Type I has an E/A ratio lesser than one, and a deceleration time of the E wave longer than 180 ms; Type II has either an E/A ratio greater than one or a deceleration time shorter than 180 ms; Type III has an E/A ratio greater than 1.6 and a deceleration time shorter than 180 ms. We also determined the pulmonary wedge pressure through a pulmonary artery catheter simultaneously with the Doppler examination on 22 occasions in 11 patients. RESULTS: Mortality rate was 13%, 9% and 35% respectively in Type I, II and III (P=0.007). After logistic regression analysis of determinants of death, including all eight variables related with mortality on an univariate analysis, only Killip class and the presence of a Type III pattern of the mitral flow remained significant (P=0.0004 and P=0.019 respectively). Pulmonary wedge pressure was 8.4+/-6.1 mmHg in Type I, 21.0+/-7.3 mmHg in Type II, and 22.4+/-7.1 mmHg in Type III (P=0.0017). CONCLUSION: Type III pattern of left ventricular filling is an independent predictor of death. Type I and II had no significant differences on prognosis. Type I is associated with a normal pulmonary wedge pressure.

Doppler transmitral flow pattern is an independent prognostic factor in acute myocardial infarction.

We analyzed the transmitral flow pattern on admission in 95 patients with acute myocardial infarction. Nineteen patients had a restrictive pattern, defined as a peak early to peak atrial filling wave ratio greater than 1.6, plus an early wave deceleration time shorter than 180 ms. Restrictive pattern, compared with nonrestrictive one, was associated with the development of heart failure (42 versus 11%, p = 0.001) and greater in-hospital mortality (32 versus 7%, p = 0.002). After multivariate analysis, it remained significantly predictive of death (p = 0.028). We conclude that a restrictive pattern of left ventricular filling in patients with acute myocardial infarction is an independent predictor of early outcome.

[Clinical and electrocardiographic characteristics of masquerading bifascicular block]. / Características clínicas y electrocardiográficas del bloqueo bifascicular disfrazado.

INTRODUCTION: Masquerading bundle branch block is a right bundle branch block with a left anterior hemiblock which appears similar to a left bundle branch block in the frontal plane leads. MATERIAL AND METHODS: We have followed 22 patients with such a pattern in the electrocardiogram for 3 years. RESULTS: Thirteen patients (59%) developed high degree atrioventricular block. During this period, there were 4 deaths, 3 from heart failure and 1 due to sepsis. CONCLUSIONS: We conclude that progression to high degree atrioventricular block is quite common in the presence of this kind of branch block. It is frequently associated to advanced heart failure, so the prognosis is usually poor.