Global Longitudinal Strain Predicts Outcomes in Patients with Reduced Left Ventricular Function Undergoing Transcatheter Edge-to-Edge Mitral Repair.

BACKGROUND: The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting. METHODS: Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (<30% or ≥30%) and median LVGLS. The primary end-point was cardiovascular mortality. RESULTS: Procedural success was high (96.5%) and complications were rare. At one-year follow-up, 82.5% of patients maintained MR grade ≤2, 79.2% were at a NYHA class ≤II and a reduction of 80% in heart failure admissions was observed in all groups. Interestingly, among patients with a more depressed LVEF, LVGLS was found to be an independent predictor for cardiovascular mortality (HR: 3.3; 95% CI: 1.1-10, p = 0.023). CONCLUSIONS: Mitral valve repair with MitraClip is safe and it improves the mid-term functional class of patients regardless of LVEF. LVGLS can help in the selection of optimal candidates and timing for this procedure, as well as in the recognition of those patients with worse prognoses.

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study.

Background: Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality. Aim: This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD. Methods: A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT. Results: Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05). Conclusion: Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Temporal trend and potential impact of angiotensin receptor neprilysin inhibitors on transcatheter edge-to-edge mitral valve repair.

INTRODUCTION AND OBJECTIVES: Transcatheter edge-to-edge repair (TEER) should be considered in patients with heart failure and secondary mitral regurgitation (MR). Angiotensin receptor-neprilysin inhibitors (ARNIs) have been demonstrated to improve prognosis in heart failure. We aimed to evaluate the impact ARNIs on patient selection and outcomes. METHODS: The population of the Spanish TEER prospective registry (March 2012 to January 2021) was divided into 2 groups: a) TEER before the ARNI era (n=450) and b) TEER after the recommendation of ARNIs by European Guidelines (n=639), with further analysis according to intake (n=52) or not (n=587) of ARNIs. RESULTS: A total of 1089 consecutive patients underwent TEER for secondary MR. In the ARNI era, there was a reduction in left ventricle dilation (82mL vs 100mL, P=.025), and better function (35% vs 38%, P=.011). At 2 years of follow-up, mortality (10.6% vs 17.3%, P <.001) and heart failure readmissions (16.6% vs 27.8%, P <.001) were lower in the ARNI era, but not recurrent MR. In the ARNI era, 1- and 2-year mortality were similar irrespective of ARNI intake but patients on ARNIs had a lower risk of readmission+mortality at 2 years (OR, 0.369; 95%CI, 0.137-0.992; P=.048), better NYHA class, and lower recurrence of MR III-IV (1.9% vs 14.3%, P=.011). CONCLUSIONS: Better patient selection for TEER has been achieved in the last few years with a parallel improvement in outcomes. The use of ARNIs was associated with a significant reduction in overall events, better NYHA class, and lower MR recurrence.

Diagnostic accuracy of regadenoson stress echocardiography: concordance with gated-spect myocardial perfusion imaging.

Regadenoson Stress Echocardiography (RSE) can detect myocardial ischemia, and its diagnostic accuracy should be evaluated. We sought to investigate the agreement between RSE and gated-SPECT myocardial perfusion imaging (MPI) and appraise its diagnostic accuracy. Consecutive patients (n = 202) referred for non-invasive evaluation of myocardial ischemia, with (38.6%) or without a previous coronary artery disease (CAD) diagnosis, were enrolled. Both tests were performed simultaneously. Invasive coronary angiography (CA) is considered the gold standard. The mean age was 70.9 (9.8) years, and 59.9% were male. The prevalence of cardiovascular risk factors (arterial hypertension [81.7%], diabetes mellitus [37.6%], hypercholesterolemia [71.8%], and smoking [18.8%]) was high. Forty-four patients (21.8%) had a non-interpretable electrocardiogram, 15 (34.1%) of them were a result of ventricular paced-rhythm, while 29 (65.9%) were a result of advanced left ventricular branch block. The overall agreement between both diagnostic techniques was good: Gwet's AC1 0.66 (CI95% 0.55 to 0.76), and it was higher in patients without a previous CAD diagnosis: 0.76 (CI95% 0.65 to 0.87). In the biased sample (those who underwent CA), RSE and nuclear study sensitivity was 0.50 and 0.78 and specificity was 0.75 and 0.75, respectively. We noted a dramatic reduction in sensitivity for RSE after debiasing (debiased sensitivity of 0.16), and the negative predictive value was similar to the biased and debiased samples. RSE is in strong agreement with gated-SPECT MPI. However, its low sensitivity and negative predictive value preclude its use as a bedside test to detect myocardial ischemia.

Ventricular arrhythmias in patients with functional mitral regurgitation and implantable cardiac devices: implications of mitral valve repair with Mitraclip®.

BACKGROUND: Limited information has been reported regarding the impact of percutaneous mitral valve repair (PMVR) on ventricular arrhythmic (VA) burden. The aim of this study was to address the incidence of VA and appropriate antitachycardia implantable cardiac defibrillator (ICD) therapies before and after PMVR. METHODS: We retrospectively analyzed all consecutive patients with heart failure with reduce left ventricular ejection fraction (LVEF), functional mitral regurgitation (FMR) grade 3+ or 4+ and an active ICD or cardiac resynchronizer who underwent PMVR in any of the eleven recruiting centers. Only patients with complete available device VA monitoring from one-year before to one year after PMVR were included. Baseline clinical and echocardiographic characteristics were collected before PMVR and at 12-months follow-up. RESULTS: Ninety-three patients (68.2±10.9 years old, male 88.2%) were enrolled. PMVR was successfully performed in all patients and device success at discharge was 91.4%. At 12-month follow-up, we observed a significant reduction in mitral regurgitation severity, NT-proBNP and prevalence of severe pulmonary hypertension and severe kidney disease. Patients also referred a significant improvement in NYHA functional class and showed a non-significant trend to reserve left ventricular remodeling. After PMVR a significant decrease in the incidence of non-sustained ventricular tachycardia (VT) (5.0±17.8 vs. 2.7±13.5, P=0.002), sustained VT or ventricular fibrillation (0.9±2.5 vs. 0.5±2.9, P=0.012) and ICD antitachycardia therapies (2.5±12.0 vs. 0.9±5.0, P=0.033) were observed. CONCLUSIONS: PMVR was related to a reduction in arrhythmic burden and ICD therapies in our cohort.

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure.

BACKGROUND: Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management. METHODS: We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke. RESULTS: Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected. CONCLUSION: TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.

Scaling Echocardiographic Cardiac Dimensions to Body Size: A Bayesian Analysis in Healthy Men and Women.

BACKGROUND: Proper scaling of cardiac dimensions is of paramount importance in making correct decisions in clinical cardiology. The usual normalization of cardiac dimensions to overall body size assumes an isometric relationship. We sought to investigate these relationships to obtain the best allometric coefficient (AC) for scaling. METHODS: Ninety-seven healthy volunteers were included. The dimensions to be scaled were the left atrial volume, the end-diastolic and end-systolic left ventricular volumes, and the diameter of the tricuspid annulus. A Bayesian statistical analysis was applied with isometric coefficients as priors. RESULTS: The linear correlations between cardiac dimensions and body size were modest, ranging from 0.12 (-0.10-0.32) for the left atrial volume and height to 0.70 (0.58-0.80) for the end-diastolic volume and height. The ACs varied across the different cardiac dimensions and body size measurements. For the best linear relationships, the isometric coefficients were outside the 95% highest density interval of the posterior distribution for the left atrial volume-weight (AC: 0.7; 0.4-0.9) and end-diastolic volume-height (AC: 2.3; 1.7-2.9), whereas they were different from 1 for the left atrial volume-weight, end-diastolic volume, and diameter of the tricuspid annulus-body surface area (AC: 0.6; 0.3-0.8). Not scaling the cardiac dimensions to their corresponding ACs can lead to important errors in size estimations of cardiac structure. CONCLUSIONS: The ACs found in this study are somewhat different from the corresponding isometric coefficients and often different from 1. This finding should be considered when normalizing cardiac structures to body size when making clinical decisions.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty.

OBJECTIVE: We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI). BACKGROUND: ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence. METHODS: Prospective cohort observational study, The primary end-point was total mortality. RESULTS: We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150). CONCLUSIONS: Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

Trileaflet Mitral Valve Treated with the MitraClip® System.

A 79-year-old woman with a history of ischemic dilated cardiomyopathy, severely depressed left ventricular ejection fraction and significant mitral regurgitation (MR) was admitted to the authors´ institution for percutaneous mitral valve repair. Transesophageal echocardiography (TEE) revealed the presence of a posterior mitral cleft at the P2 level, causing a trileaflet mitral valve that contributed significantly to the regurgitant jet. The procedure was performed under general anesthesia and guided by real-time three-dimensional TEE. Three MitraClip® devices (Abbott Vascular, Santa Clara, CA, USA) were implanted, which reduced the MR to grade 1+.

Survival Advantage of MitraClip® Over Medical Treatment in Patients with Mitral Regurgitation: A Meta-Analysis.

BACKGROUND: The MitraClip® system is a percutaneous treatment for mitral regurgitation (MR) that has shown promising results in patients who are inoperable or at high risk for mitral surgery. Data on the efficacy of the system over optimal medical therapy, above all in patients with functional MR, are scarce. The study aim was to assess the effect of MitraClip on the survival of patients with moderate/severe or severe MR compared to medical therapy, using meta-analytical techniques. METHODS: Independently, reviewers searched electronically for relevant articles based on predefined criteria and end-points. Only articles with a comparison between MitraClip and conservative therapy were included. Standard meta-analysis techniques were used. The primary outcomes were 30-day and one-year mortalities. RESULTS: Five observational reports were included that enrolled a total of 1,271 patients: 720 patients underwent percutaneous mitral valve repair (PMVR) with the MitraClip device, and 551 were managed conservatively. A total of 49 all-cause mortality events was reported at 30 days: 3.05% (22/720) in the PMVR arm, and 4.90% (27/510) in the conservative group, with no significant differences in all-cause mortality (OR 0.64; 95% CI 0.36-1.14). A total of 269 all-cause mortality events at one year was reported: 15.14% (109/720) in the PMVR arm, and 29.04% (160/551) in the conservative group. A significant difference favoring PMVR with the MitraClip system over medical therapy alone was observed (OR 0.44; 95% CI 0.30-0.64, p <0.0001). Neither significance between study heterogeneity (p = 0.18) nor publication bias was detected (p = 0.3). CONCLUSIONS: PMVR with the MitraClip system may be associated with an improvement in one-year survival compared to stand-alone medical management.

A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma.

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.

Third CoreValve™ insertion for treatment of a severe paravalvular leak after a failed valve-in-valve procedure.

An 83-year-old high-risk gentleman diagnosed with severe symptomatic aortic stenosis was scheduled for TAVR. A 31 mm CoreValve was implanted but severe paravalvular leak was noted. A valve-in-valve procedure was performed. However, the valve frame was partially dislodged into de ascending aorta. We report our strategy to solve this severe leak after a failed valve-in-valve procedure.

Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis.

Right ventricular systolic dysfunction (RVSD) has been related to prognosis in patients with heart failure (HF) and/or left ventricular systolic dysfunction. However, most of the studies addressing this issue are not large enough, have different inclusion criteria, and use different methods to evaluate RV function to draw definite conclusions. We sought to investigate the association between RVSD and outcomes in patients with left ventricular dysfunction. Eleven studies of 40 (27.5%), with 4732 patients, were included in the meta-analysis. RVSD was present in 2234 patients (47.2%). Four of the studies had admission for HF as an endpoint. We found a significant association between RVSD and overall mortality with significant between-studies heterogeneity and presence of publication bias (funnel plot). A significant association was found between RVSD and admission for HF. RVSD is associated with overall mortality and admission for HF during follow-up. Significant between-studies heterogeneity and publication bias must be taken into account when interpreting this information.

Emergency nontraumatic chest pain: use of stress echocardiography to detect significant coronary artery stenosis.

OBJECTIVE: We sought to assess the usefulness of stress echocardiography in a chest pain department. METHODS: Consecutive patients (n = 487) with nontraumatic chest pain, with no signs of myocardial ischemia on arrival to the emergency department, 6 and 12 hours later, were recruited. RESULTS: The sensitivity and specificity of stress echocardiography in the biased sample were 74% (95% confidence interval [CI] 63-85%) and 65% (95% CI 44-86%). After application of the method of Begg and Greenes to debias the sample, the calculated sensitivity was 24% (95% CI 19-29%) and specificity was 94% (95% CI 91-97%). After application of Diamond's method, sensitivity was 32% (95% CI 21-44%) and specificity (normalcy rate) was 99% (95% CI 88-100%). CONCLUSIONS: Stress echocardiography is an insensitive test when used to detect significant coronary artery stenosis in patients presenting with nontraumatic chest pain with no objective signs of myocardial ischemia.

Metaanálisis sobre la utilidad de la tomografía computarizada multicorte para la deteccion de lesiones coronarias estenóticas. Análisis coronario segmentario / Metaanalysis on the utility of multislice computed tomography to detect stenotic coronary lesions. Segmental coronary analysis

Objetivo: La tomografía computarizada multicorte (TCMC) permite la visualización de las arterias coronarias, y por tanto la detección de lesiones arterioscleróticas estenóticas. El objetivo del presente trabajo fue analizar la capacidad diagnóstica de la TCMC para la detección de lesiones estenóticas coronarias. Material y métodos: Se realizó un metaanálisis mediante búsqueda en las bases de datos MEDLINE y EMBASE de los trabajos que analizaran la sensibilidad y especificidad de la TCMC para el diagnóstico de enfermedad coronaria, mediante una división del árbol coronario por segmentos. Se incluyeron finalmente 10 estudios, con un total de 498 pacientes y 5.332 segmentos coronarios. Resultados: El porcentaje de segmentos correctamente visualizados osciló entre el 70 y el 96%. Tras la agrupación de la información proporcionada por los estudios individuales, la estimación global de la sensibilidad fue del 0,79 (intervalo de confianza [IC] del 95%, 0,77-0,81) y de la especificidad del 0,95 (IC del 95%, 0,94-0,96). Se demuestra la presencia de heterogeneidad significativa entre estudios y una curva ROC-resumen asimétrica, que corta a la diagonal para valores bajos de especificidad (8%). El área bajo la curva ROC-resumen oscila entre 0,82 y 0,89. Conclusiones: La TCMC es una prueba excelente para la detección de lesiones coronarias estenóticas en segmentos bien visualizados. Sin embargo, la curva ROC-resumen es asimétrica y existe significativa heterogeneidad entre estudios, por lo que es necesario profundizar más en la rentabilidad diagnóstica de la prueba antes de trasladar la información que proporciona a la práctica clínica diaria

Objective: The multislice computed tomography (MSCT) permits visualization of the coronary arteries and thus the detection of stenotic arteriosclerotic lesions. This present study aimed to analyze the diagnostic capacity of the MSCT to detect stenotic coronary lesions. Material and methods: A metaanalysis was conducted through the search in the MEDLINE and EMBASE data bases of the works that analyzed sensitivity and specificity of MSCT for the diagnosis of coronary disease, using a division of the coronary tree by segments. Finally 10 studies were included, with a total of 498 patients and 5322 coronary segments. Results: The percentage of the correctly visualized segments ranged from 70% to 96%. After grouping the information provided by the individual studies, global estimation of sensitivity was 0.79 (95% CI: 0.77-0.81) and specificity 0.95 (95% CI: 0.94-0.96). The presence of significant heterogeneity was demonstrated between studies and an asymmetric summary ROC curve, that cuts the diagonal line for low specificity values (8%). The area under the curve-summary ROC curve-ranges from 0.82 to 0.89. Conclusions: The MSCT is an excellent test to detect stenotic coronary lesions in well visualized segments. However, the summary ROC curve is asymmetric and there is significant heterogeneity between studies, so that it is necessary to study diagnostic profitability of the test in greater depth before transferring the information it provides to the daily clinical practice

Preinfarction angina limits myocardial infarction size in nondiabetic patients treated with primary coronary angioplasty.

OBJECTIVE: To evaluate myocardial necrosis extent after myocardial infarction (MI) and reperfusion with primary coronary angioplasty in nondiabetic patients and the relationship with unstable preinfarction angina (PA). DESIGN: Prospective cohort study. SETTING: Studies suggest PA limits infarct size. This effect is questioned in patients treated with primary coronary angioplasty. PATIENTS: Seventy-eight, nondiabetic, consecutive MI patients. INTERVENTIONS: Primary coronary angioplasty and scintigraphic study to assess the myocardial infarct size. MAIN OUTCOME MEASURES: Scintigraphic myocardial infarct size. RESULTS: There were 32 patients with PA (PA +) and 46 without PA (PA -) in the 24-h period prior to MI onset. There were no significant differences in the baseline characteristics between the two groups. The scintigraphy indicated myocardial infarct size significantly smaller in PA + patients: mean, 18.0% (SD, 14.7) vs 27.0% (SD, 20.1) [p = 0.033]. This occurs even though Thrombolysis in Myocardial Infarction grade 3 flow achieved in both groups was similar (84.8% vs 84.4%, p = 1.000). We found a higher percentage of ST-segment resolution (>/= 70%) in PA + patients (65.6% vs 45.7%, p = 0.082) together with a lower incidence of left ventricular systolic dysfunction (3.2% vs 18.6%, p = 0.071). CONCLUSIONS: PA exerts a beneficial effect in nondiabetic patients with ST-segment elevation acute MI even when treated with primary PCI. The infarct size is limited, and left ventricular systolic function is preserved. The effects may be related to a better preservation of tissue reperfusion in patients with PA.

Gestión de la lista de espera y de la actividad de los servicios quirúrgicos / Management of surgical waiting lists and activity

Introducción. Exponemos nuestra experiencia en la gestión de la lista de espera (LEQ) y la actividad de los servicios quirúrgicos, en un hospital grupo 2 del INSALUD. Los objetivos son reducir la demora en LEQ, incrementar la actividad quirúrgica, implantar un sistema de información eficaz y mejorar la gestión de pacientes. Material y método. Implantación, en agosto de 1998, de nuevas formas de gestión; desde 1999, la Circular 7/97 INSALUD; creación de la UDCA, la UCSI; gestión informática de LEQ; inicio quirófanos (a las 8.30), número intervenciones quirófano/día (> 3), índice ocupación (> 75 por ciento), suspensiones (< 3 por ciento) y programación quirúrgica; asignación mensual de quirófanos, según pacientes en lista, y envío mensual de información a los servicios. El período abarca 5 años (1997-2001). Resultados. Mayor ingreso en LEQ (el 23,98 por ciento el 2001 respecto al 2000), intervenciones (7.000/año), intervenciones ambulatorias (el 59,33 por ciento en 2001 respecto a 1997) y CMA (59,75 por ciento). Hay un 79 por ciento de ocupación quirófanos. No existen esperas de más de 6 meses (desde 1998). Menor demora media IMSALUD (27,7 días en 1998; 36,87 en 1999). Suspensiones <3 por ciento (desde 1998). Un 88,86 por ciento de intervenciones con pacientes de LEQ y un 78,82 por ciento de salidas en jornada ordinaria. Menos depuraciones (un 10,90 por ciento en 2001). Mayor complejidad (6,66 por ciento), peso medio (27,52 por ciento) y diagnósticos al alta (50 por ciento); disminución del índice de estancia media ajustada (6,66 por ciento) y de la estancia media (10,97 por ciento) en 2001 respecto a 1997. Conclusiones. Mejor gestión de lista de espera quirúrgica al unificarse en una central; la programación quirúrgica debe realizarse en sesiones clínicas, no en consulta; la Normativa del Bloque Quirúrgico aumenta su rendimiento; el nombramiento de un responsable mejora su gestión, y el mejor funcionamiento del hospital y de los servicios quirúrgicos aumenta la demanda (AU)

Valoración de la gravedad y estimación de los recursos sanitarios en los pacientes ingresados por neumonía adquirida en la comunidad / Evaluation of severity and estimation of resource use in patients hospitalized for community-acquired pneumonie

Introducción: Los recursos sanitarios que se precisan para el adecuado tratamiento de la neumonía adquirida en la comunidad (NAC) podrían estar en relación con la gravedad del proceso. Objetivos: Comprobar la distribución de grupos relacionados con el diagnóstico (GRD) en los pacientes ingresados por NAC, así como determinar si el peso específico, como medida del uso de recursos sanitarios, está relacionado con la gravedad clínica de la NAC. Métodos: Estudio retrospectivo con pacientes ingresados en nuestra unidad y diagnosticados de NAC durante un año, que recoge datos demográficos, clínicos, así como datos referentes a GRD, peso específico y estancia hospitalaria. Resultados: Se estudió a 129 pacientes con una edad media de 71 años (DE: 17), el 70 por ciento de los cuales se asignaron a las clases de riesgo más alto (clases IV y V). Los GRD más frecuentes fueron: GRD 89 (35,7 por ciento), GRD 90 (34 por ciento) y GRD 541 (17,8 por ciento). A excepción de la clase I, no hubo diferencias entre el peso específico de las clases de riesgo. Se observó una correlación muy baja entre el peso específico y la puntuación por la escala de Fine o la estancia hospitalaria. Los pacientes fallecidos, a pesar de que presentaban un mayor grado de gravedad que los supervivientes, no tienen diferencias significativas con respecto al peso específico de los que no fallecieron. Conclusiones: Los pacientes ingresados por neumonía tienen un alto nivel de gravedad clínica y los GRD asignados al alta más frecuentes en nuestra serie fueron aquellos relacionados directamente con la neumonía (89 y 90). La gravedad clínica de los pacientes con NAC no parece reflejarse en el peso específico asignado (AU)