Combined mitral and tricuspid valve repair in rheumatic valve disease: fewer reoperations with prosthetic ring annuloplasty.

BACKGROUND: We examined predictors of early and very long-term outcome after combined mitral and tricuspid valve repair for rheumatic disease. METHODS AND RESULTS: Between 1974 and 2002, 153 consecutive patients (mean age, 46.0+/-13.2 years) underwent combined mitral and tricuspid valve repair for rheumatic disease. Mitral disease was predominantly stenosis (82.3%); 100% of patients had organic tricuspid valve disease, predominantly with regurgitation (53.6%) or some degree of tricuspid stenosis (46.4%). Mitral repair included commissurotomy in 132 patients (86.3%) associated with a flexible annuloplasty in 108. Tricuspid valve repair included flexible annuloplasty in 68 patients (44.4%) and suture annuloplasty in 20 patients (13.1%) combined with tricuspid commissurotomy in 62 patients (42.5%). Thirty-day mortality was 5.9%. Late mortality was 60.1%. The median follow-up was 15.8 years (interquartile range, 6 to 19 years). Follow-up was 97.9% complete. Age>65 years was the only predictor of late mortality. Kaplan-Meier survival probability was 74.4% at 10 years and 57.0% at 15 years. Sixty-three patients required valve reoperation (mitral valve, 59; tricuspid valve, 38). Predictors of valve reoperations were either mitral or tricuspid commissurotomy without associated prosthetic ring annuloplasty. At 20 years, Kaplan-Meier freedom from reoperation was 48.5+/-5.1%. CONCLUSIONS: Combined mitral and tricuspid valve repair in rheumatic disease showed satisfactory early results. Long-term results were poor because of high mortality and a high number of valve-related reoperations. The use of prosthetic ring annuloplasty was significantly associated with a reduced incidence of both mitral and tricuspid valve reoperations.

[Cardiac cephalgia: an underdiagnosed condition? ]. / Cefalea cardíaca: 'una entidad infradiagnosticada?

Cardiac cephalgia, or headache occurring as manifestation of myocardial ischemia, has only recently been recognized as a distinct entity. In patients with known ischemic cardiopathy, its diagnosis depends on the presence of severe headache that is accompanied by nausea, worsened by physical exercise, and only ceases with nitrate administration. We report on two patients who met diagnostic criteria for this entity. In both, headache was the only symptom of coronary ischemia, and delayed its diagnosis. Headache occurred both at rest and during exertion, and resolved only after the administration of nitrates. Cardiac cephalgia should be suspected in patients with a history of ischemic cardiopathy who present with de novo headache, even when thoracic pain is absent, especially if the headache improves with nitrates. Differential diagnosis with migraine is crucial to avoid the administration of vasoconstrictors.

Cefalea cardíaca: ¿una entidad infradiagnosticada? / Cardiac cephalgia: an underdiagnosed condition?

La cefalea cardíaca, o cefalea como manifestación de isquemia miocárdica, es una entidad individualizada recientemente. Su diagnóstico en un paciente con cardiopatía isquémica requiere una cefalea intensa, acompañada de náuseas y empeorada por el ejercicio, que cede tras la administración de nitratos. Presentamos los casos de 2 pacientes que cumplían estos criterios diagnósticos. En ambos, esta cefalea fue el único síntoma de isquemia coronaria, lo que retrasó el diagnóstico, aconteció con esfuerzos y en reposo, y sólo cedió tras la administración de nitratos. La cefalea cardíaca ha de sospecharse en pacientes con cardiopatía isquémica que consultan por cefalea de reciente comienzo, aunque no presenten dolor torácico, sobre todo si mejoran con nitratos. El diagnóstico diferencial con la migraña es crucial de cara a evitar medicaciones vasoconstrictoras

Cardiac cephalgia, or headache occurring as manifestation of myocardial ischemia, has only recently been recognized as a distinct entity. In patients with known ischemic cardiopathy, its diagnosis depends on the presence of severe headache that is accompanied by nausea, worsened by physical exercise, and only ceases with nitrate administration. We report on two patients who met diagnostic criteria for this entity. In both, headache was the only symptom of coronary ischemia, and delayed its diagnosis. Headache occurred both at rest and during exertion, and resolved only after the administration of nitrates. Cardiac cephalgia should be suspected in patients with a history of ischemic cardiopathy who present with de novo headache, even when thoracic pain is absent, especially if the headache improves with nitrates. Differential diagnosis with migraine is crucial to avoid the administration of vasoconstrictors

Reoperations after tricuspid valve repair.

OBJECTIVE: The objective was to analyze the short- and long-term results of patients with previous tricuspid valve repair who had valve dysfunction and required cardiac reoperations. METHODS: Between 1976 and 2002, 74 patients with a mean age of 53.8 +/- 12.2 years underwent valve reoperations for dysfunction of previous tricuspid valve repair. Mitral and tricuspid lesions were diagnosed in 40 patients (54%), triple valve disease (mitral, aortic, tricuspid) was diagnosed in 26 patients (35.1%), isolated tricuspid disease was diagnosed in 6 patients (8.1%), and aortic and tricuspid lesions were diagnosed in 2 patients (2.7%). Reoperations included tricuspid valve replacement in 43 patients (58.1%) and a new tricuspid valve repair procedure in the remaining 31 patients (41.9%). RESULTS: Hospital mortality (30-day or within first admission) was 35.1% (n = 26). In the multivariate analysis, risk factors for hospital mortality included body mass index less than 20 kg/m2 and greater than 24 kg/m2 , triple valve disease, use of intra-aortic balloon counterpulsation, and presence of postoperative complications. The follow-up was complete in 100% of patients, with a mean follow-up of 14.2 years (range 4 months to 26 years). The late mortality was 40.5% (n = 30). Predictors of late mortality were body mass index less than 20 kg/m2 , cardiac surgery before 1991, and development of dysfunction early after tricuspid valve repair. At the follow-up closing date, 19 patients are alive (25.7%). The actuarial survival was 11.8% +/- 4.9% at 26 years. CONCLUSIONS: Patients with failure of a tricuspid valve repair procedure requiring reoperation have a poor prognosis with a high mortality rate both in-hospital and in the long-term.

Tricuspid valve repair: an old disease, a modern experience.

BACKGROUND: We review our experience in patients who required surgical correction of tricuspid valve disease with concomitant disease of the mitral or aortic valve, or both, operated on between 1987 and 1999. METHODS: We studied 232 consecutive patients (mean age, 59.8 years) followed for a mean of 6.8 years (range, 2 to 12 years). All patients were investigated by means of Doppler echocardiography, with hemodynamic studies in 135. Median tricuspid insufficiency was 3+. The cause was rheumatic heart disease in 186 patients and degenerative in 46. All patients underwent suture annuloplasty (De Vega or segmental) at the time of mitral or aortic valve surgery. Tricuspid lesions were functional in 128 patients and organic in 104. RESULTS: The hospital and late mortality rates were 8.1% and 23.3%, respectively. These figures were independent of the type of annuloplasty performed. Predictors of hospital mortality were biologic prosthesis, renal insufficiency, time of cardiopulmonary bypass, and use of inotropic drugs. Predictors of late mortality were age older than 60 years, left ventricular ejection fraction less than 0.50, and New York Heart Association functional class IV. At 12 years, the actuarial survival rate was 50.5% +/- 6.1%, and the actuarial curve free from reoperation 75.7% +/- 7.3%. The actuarial curve for freedom from valve-related complication was 39.0% +/- 6.3% at 11 years. CONCLUSIONS: Despite the use of modern technologic advances in the diagnosis and treatment of valvular hear disease, tricuspid insufficiency continues to be a poor prognostic factor in patients with concomitant disease of the mitral or aortic valve, or both.

Gestión clínica y sentido común / Clinical management and common sense

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Guías de práctica clínica de la Sociedad Española de Cardiología sobre requerimientos y equipamiento de la unidad coronaria / Guidelines of the Spanish Society of Cardiology on Requirements and Equipment of the Coronary Care Unit

Los autores plantean el cambio conceptual y en la dinámica asistencial ocurridos en los últimos años en la unidad coronaria. Se exponen los criterios de planificación y organización funcional y jerárquica, así como los argumentos asistenciales básicos para su desarrollo. Las unidades coronarias no deben constituirse de manera aislada sino integradas en el servicio de cardiología, y siempre deben estar dirigidas por un cardiólogo. La unidad coronaria se concibe cada vez más como una unidad de cuidados intensivos para pacientes con cardiopatías agudas o crónicas agudizadas. Se indican las características de su estructura física y equipamiento, así como las del área de cuidados intermedios y de las recientemente creadas camas de dolor torácico. Por último, se comentan los recursos humanos y los criterios de admisión y alta en la unidad coronaria (AU)