Comprehensive multidisciplinary patient assessment and selection before TAVI procedure.

Aortic stenosis is a common disorder that affects nearly 5% of persons >75 years of age. Aortic valve replacement is indicated for symptomatic patients with severe aortic stenosis, as the prognosis of untreated patients is poor. Nevertheless, many patients with symptomatic severe aortic stenosis do not undergo surgical valve replacement, which has been attributed to comorbidities. Transcatheter aortic valve implantation (TAVI) is a novel method to treat selected high-risk patients with aortic stenosis. Patient screening and anatomic measurements of the aortic root are of great importance to ensure procedural success and appropriate patient selection. This review outlines comprehensive multidisciplinary assessment and selection of these patients and the evolving role of the echocardiogram and the multislice computed tomography in support of TAVI program.

Long-term results after transcatheter aortic valve implantation: positive and side effects.

The scientific and technological progress in the field of medicine has allowed to treat patients with severe aortic valve stenosis and with a high perioperative risk. Before the introduction of transcatheter aortic valve implantation (TAVI), patients considered at high risk for surgical treatment were managed with medical therapy or with balloon aortic valvuloplasty. With more than 50000 transcatheter aortic valves implanted in patients around the world, TAVI has demonstrated to be a valid alternative to surgical aortic valve replacement in inoperable and high-risk patients. The PARTNER trial was the first randomized controlled trial to demonstrate that TAVI is not inferior to SAVR in high-risk patients. However, despite some encouraging short-term results medium and long-term outcomes are not always so encouraging. In this review, we will present the immediate results and distinct TAVI-related drawbacks and relative impact on the long-term outcome. New technology advances promise to simplify TAVI and to improve the results by reducing the rate of TAVI-specific issues such as paravalvular aortic regurgitation, annular rupture, and conduction disturbances which may impact on the clinical outcome. Therefore, we believe that when some of these weaknesses will be overcome, even patients at lower risk might benefit from TAVI in the near future.

Patient selection for MitraClip therapy impaired left ventricular systolic function.

Mitral regurgitation (MR) is a disabling disease associated with poor prognosis and high incidence of clinical events if left untreated. To reduce the invasiveness of the surgical approach, different types of transcatheter procedures are becoming available. The MitraClip procedure (Abbott Vascular Inc. Menlo Park, CA, USA) is yet the only catheter-based procedure available in clinical practice at the moment. The device has been evaluated in a number of preclinical studies, registries and in FDA approved clinical trials. (EVEREST trial, ACCESS-EU trial). Indication and timing of intervention is a crucial step in the diagnostic-therapeutic pathway of patients with mitral regurgitation. The aim of this review is to clarify the potential of MitraClip in clinical practice, particularly focusing on patient selection for this novel therapy. Patient selection and overall decision making is strongly influenced by anatomical and clinical factors. Decision-making in degenerative MR (DMR) vs. functional (FMR) can be quite different. Generally, MitraClip is effective in treating either type II or IIIb dysfunction (at the moment FMR is the main indication for MitraClip in Europe, according to the ACCESS registry data). The relative role of MitraClip and surgery in the management of patients with MR is still unclear. From the global initial experience, MitraClip therapy could be complementary to surgery in those patients at high risk for surgery who have ideal anatomical characteristics for implantation. The procedure is quite predictable in patients with favorable anatomy. In patients with suboptimal anatomy, if the risk of surgery is too high, MitraClip could be still indicated sometimes. Our preliminary experience suggests that in patients with DMR, the EVEREST anatomical criteria are strong predictors of early and mid-term success. According to it, MitraClip therapy is appropriate in those DMR patients with high surgical risk and ideal anatomy for clip implantation according to the EVEREST criteria. In FMR refractory to medical therapy and resynchronization therapy, MitraClip could be considered as first option therapy, particularly in those patients with comorbidities, or advanced age, being the operative risk of surgery above 5% in this population. In the future, novel devices, improved knowledge, more efficient imaging and transcatheter mitral prosthetic valve implantation may expand the indications to those patients currently not treated by MitraClip for anatomical unsuitability, and may improve the results both in term of early efficacy and long term durability.

Coronary chronic total occlusion.

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains a major challenge in interventional cardiology. Successful recanalization of a CTO can alleviate angina, reduce the need for coronary artery bypass surgery and increase long-term survival. Improving results from the historically quoted success rates of 50% to the levels now routinely quoted by some operators (80-90%), requires not just skill and experience, but also a thorough understanding of the wide array of materials and techniques now available in this area. The decision to attempt PCI of a CTO (versus continued medical therapy or surgical revascularization) requires an individualized risk/benefit analysis, encompassing clinical, imaging and technical considerations.

[Incidence of streptococcal pharyngitis]. / Incidencia de faringitis estreptocócica.

OBJECTIVE: To determine the incidence of streptococcal pharyngitis in patients younger than 2 years of age, and to evaluate the role of group C streptococci as a pathogenic agent in acute pharyngitis through throat culture in symptomatic patients. MATERIAL AND METHODS: We performed a retrospective descriptive study of patients with clinical symptoms of acute pharyngitis and fast detection of streptococcal antigen and/or exudate culture who attended the emergency department between February 2004 and February 2005. RESULTS: Group A beta-hemolytic streptococcus (GAS) was isolated by pharyngeal culture in 85 patients aged less than 2 years (12.6%). In these patients the fast test displayed lower sensitivity and positive predictive value (PPV) (sensitivity: 78%; PPV: 69%, p < 0.01). Patients aged less than 2 years had a greater frequency fever, exanthema and catarrhal symptoms than older children (p < 0.01). In the younger age group, erythromycin resistance rates increased to 24.7% (p = 0.08). Group C streptococcus was isolated in 5.2% (43 patients). The most frequent reason for consultation was fever (74.4%) and the most common findings on examination were abnormal pharynx in 90.7%, odynophagia and adenopathies in 55.8%. Two incidence peaks (in May and September) were observed, with sporadic cases throughout the year. CONCLUSIONS: In our sample, the percentage of GAS in patients aged less than 2 years was higher than that reported in other series. In this age group, the sensitivity of the fast test is lower than in other age groups and there is a higher rate of erythromycin resistance. The percentage of tonsillitis due to serotype C was also slightly higher than expected. Two peaks of incidence were observed, similar to those occurring with SGA, with sporadic cases throughout the year.

Incidencia de faringitis estreptocócica / Incidence of streptococcal pharyngitis

Objetivo Determinar la incidencia de infección estreptocócica en pacientes menores de 2 años y la frecuencia y distribución estacional del serotipo C mediante cultivo de exudado faríngeo en pacientes sintomáticos. Material y métodos Estudio retrospectivo, descriptivo de los pacientes con clínica faringoamigdalar aguda y positividad de test de detección rápida de antígeno estreptocócico y/o cultivo de exudado faríngeo, que acudieron a urgencias en el período de un año (febrero de 2004-febrero de 2005). Resultados El estreptococo del grupo A (SGA) se aisló mediante cultivo faríngeo en 85 pacientes menores de 2 años (12,6 %). En estos pacientes el test rápido presentaba menor sensibilidad (S) y valor predictivo positivo (VPP) (S 78%-VPP 69 %; p < 0,01). Los menores de 2 años presentaban con más frecuencia fiebre, exantema y síntomas catarrales con respecto al grupo de niños mayores (p < 0,01). En este grupo de edad aumentan las tasas de resistencia a eritromicina hasta el 24,7 % (p 0,08). El estreptococo del grupo C se aisló en un 5,2 % (43). La fiebre fue el motivo de consulta más frecuente (74,4 %), los hallazgos más habituales en la exploración fueron la faringe anormal en un 90,7 %, odinofagia y adenopatías en un 55,8 %. Observamos 2 picos de incidencia en mayo y en septiembre, con casos esporádicos durante todo el año. Conclusiones En nuestra muestra hemos encontrado un porcentaje superior a otras series de SGA en pacientes menores de 2 años. En este grupo de edad, se observa menor sensibilidad del test rápido, así como mayor tasa de resistencia a eritromicina. El porcentaje de amigdalitis por serotipo C encontrado, es también ligeramente superior al esperado. Se observan 2 picos de incidencia similares a los presentados por SGA, con casos esporádicos durante todo el año

Objective To determine the incidence of streptococcal pharyngitis in patients younger than 2 years of age, and to evaluate the role of group C streptococci as a pathogenic agent in acute pharyngitis through throat culture in symptomatic patients. Material and methods We performed a retrospective descriptive study of patients with clinical symptoms of acute pharyngitis and fast detection of streptococcal antigen and/or exudate culture who attended the emergency department between February 2004 and February 2005. Results Group A beta-hemolytic streptococcus (GAS) was isolated by pharyngeal culture in 85 patients aged less than 2 years (12.6 %). In these patients the fast test displayed lower sensitivity and positive predictive value (PPV) (sensitivity: 78 %; PPV: 69 %, p < 0.01). Patients aged less than 2 years had a greater frequency fever, exanthema and catarrhal symptoms than older children (p < 0.01). In the younger age group, erythromycin resistance rates increased to 24.7 % (p 0.08). Group C streptococcus was isolated in 5,2% (43 patients). The most frequent reason for consultation was fever (74.4 %) and the most common findings on examination were abnormal pharynx in 90.7 %, odynophagia and adenopathies in 55.8 %. Two incidence peaks (in May and September) were observed, with sporadic cases throughout the year. Conclusions In our sample, the percentage of GAS in patients aged less than 2 years was higher than that reported in other series. In this age group, the sensitivity of the fast test is low-er than in other age groups and there is a higher rate of erythromycin resistance. The percentage of tonsillitis due to serotype C was also slightly higher than expected. Two peaks of incidence were observed, similar to those occurring with SGA, with sporadic cases throughout the year

[Carboxyhemoglobin levels and risk factors of carbon monoxide poisoning in children;]. / Concentraciones de carboxihemoglobina y factores de riesgo de intoxicación por monóxido de carbono en niños.

BACKGROUND: To determine carboxyhemoglobin levels and to investigate carbon monoxide poisoning risk in children. PATIENTS AND METHODS: We determine carboxyhemoglobin blood levels by cooximetry in 65 children, between 15 days and 15 years attended in a pediatric emergency section. We analyze carbon monoxide risk factors (type of heating and smokers in the family). RESULTS: Mean carboxyhemoglobin levels in 59 children without acute intoxication was 0.5 +/- 0.87% (range 0-3.8%). There are no significant differences with respect to age and sex. Children with wood or coal heating (0.88 +/- 1.34%) and gas heating (0.58 +/- 0.97%) have carboxyhemoglobin levels higher than children with electric heating (0.28 +/- 0.4%) but differences were no statistically significant. Four patients have carboxyhemoglobin levels > 2%, two with coal or wood hating and two with gas heating. Children with smokers in the family have carboxyhemoglobin levels higher than the rest of children (0.65 +/- 1.05% versus 0.34 +/- 0.45%) without statistical significance. The four children with carboxyhemoglobin levels > 2% live with smokers. Six children suffered carbon monoxide poisoning with carboxyhemoglobin levels between 20.6 and 36.6%. CONCLUSIONS: Mean carboxyhemoglobin levels in children are low. There are carbon monoxide poisoning risk factors (wood, coal or gas heating at home, and smokers in the family) in a high percentage of the children, although they did not show statistical significance.

Twins with nonconcordant sexual aneuploidy.

We present a pair of dizygotic twins with different abnormal karyotypes. The chromosome anomaly is a sexual aneuploidy in both cases: 48,XXXXY in one, 47,XXY in the second. The origin of the chromosomal anomaly and the hypothetical relation between sexual aneuploidy and twinning is discussed. It is concluded that further studies in twins are necessary to prove the not yet solved problems of non-disjunction and double ovulation.