Right ventricular function and N-terminal pro-brain natriuretic peptide levels in adult patients with simple dextro-transposition of the great arteries.

INTRODUCTION: Dextro-transposition of the great arteries (d-TGA) patients is at high risk of developing right ventricular dysfunction and tricuspid regurgitation in adulthood. Determining the relation between echocardiographic parameters, N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels and the New York Heart Association (NYHA) functional class may help determining the best time to operate them. METHODS: Patients with simple d-TGA operated in infancy with an atrial switch procedure (Mustard or Senning operation) were followed up in our Adult Congenital Heart Disease Unit. Analytical, echocardiographic, and clinical parameters were determined to evaluate the correlation between right echocardiographic ventricular function, NT-pro-BNP levels, and NYHA functional class. RESULTS: Twenty-four patients with d-TGA were operated in infancy of whom 17 alive patients had simple d-TGA. Nine patients had NT-pro-BNP levels lower than 200 pg/mL and eight patients were above 200 pg/mL. Patients with lower hemoglobin concentration, higher right ventricular diameter or under diuretic treatment showed significant higher NT-pro-BNP levels (above 200 pg/dL). The Spearman test showed a positive correlation between basal right ventricular diameter and tricuspid regurgitation with pro NT BNP levels (correlation coefficient of .624; P=.017 and .490; P=.046, respectively) and a negative correlation with the right ventricle fractional area change (-.508, P=.045). No correlation was seen between NT-pro-BNP levels and the rest of echocardiographic parameters or the NYHA functional class. CONCLUSION: NT-pro-BNP levels showed a positive correlation with basal right ventricular diameter and tricuspid regurgitation but not with NYHA association functional class in d-TGA patients.

Hereditary Hemorrhagic Telangiectasia and Myocardial Infarction.

Hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu syndrome, is an autosomal dominant genetic disorder that leads to epistaxis, gastrointestinal bleeding, iron deficiency anemia, and arteriovenous malformations at the lungs, the liver, and the brain. However, due to its rarity and its unspecific findings on routine examinations, diagnosis is not easy unless suspected due to hypoxemia or paradoxical embolism. We present a case of a 46-year-old-woman with hereditary hemorrhagic telangiectasia and hypoxemia who presented a myocardial infarction secondary to paradoxical embolism through pulmonary arteriovenous malformations.

Acute Coronary Syndromes, Gastrointestinal Protection, and Recommendations Regarding Concomitant Administration of Proton-Pump Inhibitors (Omeprazol/Esomeprazole) and Clopidogrel.

The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. The purpose is to know the gastroprotective approach in patients with acute coronary syndrome (ACS) and the level of follow-up of the alert. In 17 hospitals with catheterization laboratory in Spain, 1 per region, we studied 25 consecutive patients per hospital whose diagnosis of discharge since October 1, 2013, had been any type of ACS. We analyzed their baseline clinical profile, the gatroprotective agents at admission and discharge and the antiplatelet therapy at discharge. The number of patients included was 425: age 67.2 ± 12.5 years, women 29.8%, diabetes 36.5%. The patients presented unstable angina in 21.6%, non-ST-elevation myocardial infarction in 35.3% and ST-elevation myocardial infarction in 43.1%. Conservative approach was chosen in 17.9%, bare-metal stents 32.2%, ≥ 1 drug-eluting stent 48.5%, and surgery 1.4%. Aspirin was indicated in 1.9%, aspirin + clopidogrel 73.6%, aspirin + prasugrel 17.6%, and aspririn + ticagrelor 6.8%. Gastroprotective agents were present in 40.2% patients at admission and this percentage increased to 93.7% at discharge. Of the 313 (73.6%) on clopidogrel in 96 (30.6%) was combined with omeprazole and 3 (0.95%) with esomeprazole, whereas the most commonly used was pantoprazole with 190 patients (44.7%). In conclusion, almost the totality of the patients with an ACS receive gastroprotective agents at the moment of discharge, most of them with proton-pump inhibitors. In one every 3 cases of the patients who are on clopidogrel, the recommendation of the Food and Drug Administration and the European Medicines Agency is not followed.

Diving and percutaneous closure of persistent (patent) foramen ovale.

Paradoxical arterial gas embolism after diving, in patients with a persistent foramen ovale (PFO) is a potentially catastrophic complication that occurs when gas bubbles occlude blood flow at cardiac or cerebral level. Because the relationship between PFO and decompression illness is currently not clear, we should ensure that patients understand the uncertainties about the efficacy of transcatheter closure of a PFO and the possibility of complications if closure is decided upon. We report a female diver who developed temporary bradycardia, hypotension and evidence of myocardial ischaemia during a closure procedure.

Síndrome de discinesia apical transitoria durante ecocardiografía de estrés con dobutamina / Transient apical ballooning syndrome during dobutamine stress echocardiography

El síndrome de discinesia apical transitoria, o síndrome de Tako-Tsubo, tiene un inicio de presentación agudo, es más frecuente en mujeres posmenopáusicas, y se caracteriza por discinesia apical transitoria del ventrículo izquierdo, dolor torácico, trastornos electrocardiográficos y ligera elevación de los marcadores de daño miocárdico que pueden simular un infarto de miocardio en pacientes con coronarias sin lesiones significativas. Sin embargo, antes de realizar su diagnóstico debemos descartar otras causas de disfunción ventricular izquierda reversible como son la hemorragia subaracnoidea, las crisis de feocromocitoma, la miocarditis aguda o la presencia de taquicardiomiopatía. Presentamos el caso de una paciente que desarrolló trastornos electrocardiográficos de elevación del segmento ST con discinesia apical transitoria durante una ecocardiografía de estrés con dobutamina

The transient left ventricular apical ballooning syndrome, also known as Tako-Tusbo syndrome, has an acute onset, is more common in postmenopausal women, and is characterized by transient left ventricular apical ballooning, chest pain, electrocardiographic abnormalities, and slight elevation of markers for myocardial injury, mimicking a myocardial infarction in patients with no significant coronary lesions. However, before making the diagnosis, other causes of reversible left ventricular dysfunction must be ruled out, such as subarachnoid hemorrhage, pheochromocytoma crisis, acute myocarditis, or the presence of tachycardiomyopathy. The case is presented of a patient who developed ST elevation electrocardiographic changes with apical transient dyskinesia during dobutamine stress echocardiography

[Transient apical ballooning syndrome during dobutamine stress echocardiography]. / Síndrome de discinesia apical transitoria durante ecocardiografía de estrés con dobutamina.

The transient left ventricular apical ballooning syndrome, also known as Tako-Tusbo syndrome, has an acute onset, is more common in postmenopausal women, and is characterized by transient left ventricular apical ballooning, chest pain, electrocardiographic abnormalities, and slight elevation of markers for myocardial injury, mimicking a myocardial infarction in patients with no significant coronary lesions. However, before making the diagnosis, other causes of reversible left ventricular dysfunction must be ruled out, such as subarachnoid hemorrhage, pheochromocytoma crisis, acute myocarditis, or the presence of tachycardiomyopathy. The case is presented of a patient who developed ST elevation electrocardiographic changes with apical transient dyskinesia during dobutamine stress echocardiography.