La consulta de acto único en cardiología / One-stop consultation in cardiology

El modelo de consulta de alta resolución está en expansión. La cardiología es una de las especialidades que más se beneficia de ella. El sistema está avalado por indudables ventajas, en especial, la agilidad en la estrategia diagnóstico-terapéutica. Sin embargo, no debe considerarse un modo exclusivo de asistencia especializada. Puede y debe coexistir con la asistencia tradicional, pues ciertas exploraciones no son subsidiarias de alta resolución. Además, pueden surgir limitaciones en la implementación del modelo y/o en sus resultados, debido a la escasez de recursos, a una inadecuada organización de éstos, o a la reducida rentabilidad de determinadas exploraciones en enfermedades concretas. No se puede considerar una limitación la necesidad de seguimiento posterior de los pacientes, ya que éste nada tiene que ver con la capacidad resolutiva del modelo y se realiza de forma similar a las consultas tradicionales (AU)

The use of one-stop consultations is growing. Cardiology is one of the specialties that will benefit most from it. The approach has undoubted advantages, such as, in particular, the speed of the diagnostic and therapeutic processes. Nonetheless, this approach should by no means be considered the only way of providing specialized care. It can and should coexist with traditional care since some investigations cannot be incorporated into the one-stop consultation model. Furthermore, the implementation of this approach or of its findings may be limited by a lack of resources, poor organization, or the low cost-effectiveness of particular investigations into certain conditions. The need for subsequent follow-up in patients should not be considered as a limitation of the approach since it does not affect its decision-making ability. Moreover, follow-up can take the same form as it would with traditional consultations (AU)

[Comparative analysis of antioxidant defense during on-pump and off-pump cardiac surgery]. / Análisis comparativo de la defensa antioxidante en cirugía cardíaca con y sin circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: The transient myocardial ischemia that occurs during cardiac surgery leads to oxidative stress and the production of free radicals. The resulting damage can be reduced if cardiopulmonary bypass is avoided. We obtained indirect measures of the oxidative damage occurring during cardiac surgery by monitoring the glutathione system and we studied the influence of cardiopulmonary bypass. PATIENTS AND METHOD: The study included 19 patients undergoing cardiac surgery. Cardiopulmonary bypass was used in 9 (47.4%). Blood samples were obtained from each patient at different times during and after surgery. Total, oxidized and reduced glutathione levels were measured, as was the activity of related enzymes (i.e., glutathione peroxidase, glutathione reductase, and glutathione transferase). RESULTS: The total glutathione level decreased more in patients in whom cardiopulmonary bypass had been used. In addition, the oxidized glutathione level was reduced in these patients, which suggests that antioxidant defense was not fully effective. In contrast, the oxidized glutathione level tended to increase in patients in whom cardiopulmonary bypass had not been used. There was no significant difference in enzymatic activity between the two groups. CONCLUSIONS: In this study, patients who underwent off-pump cardiac surgery had a better antioxidant profile. The implication could be that cardiac surgery without cardiopulmonary bypass has a less damaging effect on ischemic myocardium.

Análisis comparativo de la defensa antioxidante en cirugía cardíaca con y sin circulación extracorpórea / Comparative analysis of antioxidant defense during on-pump and off-pump cardiac surgery

Introducción y objetivos. Durante la cirugía cardíaca se produce una isquemia miocárdica transitoria que implica el desarrollo de fenómenos de estrés oxidativo con liberación de radicales libres. El daño resultante puede ser menor si se obvia el bypass aortopulmonar. Se estudia el sistema antioxidante del glutatión como medida indirecta del daño oxidativo asociado con la cirugía cardíaca. Se analiza la influencia del empleo de circulación extracorpórea. Pacientes y método. Se incluye a 19 pacientes en los que se realizó cirugía cardíaca, 9 de ellos con bomba (47,4%). De cada paciente se extrajeron muestras sanguíneas en diferentes momentos (intraoperatorios y postoperatorios) y en ellas se cuantificaron el glutatión (total, oxidado y reducido) plasmático e intraeritrocitario y se determinó la actividad enzimática implicada (glutatión-peroxidasa, glutatión-reductasa y glutatión-transferasa).Resultados. El glutatión total disminuyó más en los pacientes operados con circulación extracorpórea. También se redujo el glutatión oxidado plasmático e intraeritrocitario, lo que expresa una defensa antioxidante ineficaz, mientras que en los casos sin bomba esta tendencia fue creciente. No hubo diferencias significativas en la actividad enzimática entre ambos grupos. Conclusiones. En nuestra serie, los pacientes intervenidos sin circulación extracorpórea mostraron un mejor perfil antioxidante en relación con el sistema del glutatión. Esto puede traducirse en que la cirugía cardíaca sin bomba resulta menos agresiva para el miocardio

Introduction and objectives. The transient myocardial ischemia that occurs during cardiac surgery leads to oxidative stress and the production of free radicals. The resulting damage can be reduced if cardiopulmonary bypass is avoided. We obtained indirect measures of the oxidative damage occurring during cardiac surgery by monitoring the glutathione system and we studied the influence of cardiopulmonary bypass.Patients and method. The study included 19 patients undergoing cardiac surgery. Cardiopulmonary bypass was used in 9 (47.4%). Blood samples were obtained from each patient at different times during and after surgery. Total, oxidized and reduced glutathione levels were measured, as was the activity of related enzymes (i.e., glutathione peroxidase, glutathione reductase, and glutathione transferase). Results. The total glutathione level decreased more in patients in whom cardiopulmonary bypass had been used. In addition, the oxidized glutathione level was reduced in these patients, which suggests that antioxidant defense was not fully effective. In contrast, the oxidized glutathione level tended to increase in patients in whom cardiopulmonary bypass had not been used. There was no significant difference in enzymatic activity between the two groups. Conclusions. In this study, patients who underwent off-pump cardiac surgery had a better antioxidant profile. The implication could be that cardiac surgery without cardiopulmonary bypass has a less damaging effect on ischemic myocardium

Insuficiencia mitral traumática diferida / Delayed post-traumatic mitral regurgitation

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Seguimiento a largo plazo tras la ablación con radiofrecuencia de taquicardias ventriculares en pacientes portadores de un desfibrilador automático implantable / Radiofrequency catheter ablation of ventricular tachycardia in patients with an implantable defibrillator. Long-term follow-up

Introducción y objetivos. La aparición de episodios frecuentes de taquicardia ventricular es un problema para los pacientes portadores de un desfibrilador implantable y en ocasiones requiere la combinación de un tratamiento antiarrítmico o una ablación con radiofrecuencia. Hemos analizado los resultados de esta técnica en el grupo de pacientes portadores de desfibrilador por taquicardia ventricular sincopal previa que presentaron taquicardia ventricular frecuente o incesante. Pacientes y método. Se realizaron 18 procedimientos de ablación en 11 varones de 67,64 ± 5,87 años con estas características; 10 pacientes habían presentado un infarto de miocardio 15,50 ± 5,08 años antes y otro tenía una displasia arritmogénica del ventrículo derecho. Hasta la ablación se produjeron 591,67 ± 1.020,34 episodios de taquicardia ventricular (rango, 7-2.604).Resultados. El éxito electrofisiológico inicial fue del72,73% (n = 8). Tras un seguimiento de 39,10 ± 24,70meses, el número de descargas del desfibrilador disminuyó significativamente en todos los pacientes y pasó de52,82 ± 35,73 (rango, 7-130) a 0,64 ± 1,03 (rango, 0-3)(p = 0,001); 9 pacientes presentaron posteriormente alguna taquicardia ventricular; 6 enfermos necesitaron nuevos intentos de ablación (2 por fracaso inicial, 3 por recurrencia y 1 por una taquicardia diferente). Con independencia del resultado electrofisiológico, todos los pacientes presentaron buena evolución clínica a largo plazo. Conclusiones. La ablación con radiofrecuencia interrumpe de manera eficaz la situación de taquicardia ventricular incesante o muy recurrente y reduce significativamente las descargas del desfibrilador, incluso tras el fracaso electrofisiológico, y es especialmente útil en estas situaciones críticas, cuando otras terapias resultan ineficaces o insuficientes. Dado que nuestros pacientes son mayoritariamente isquémicos y muy proclives a presentar nuevos eventos arrítmicos durante su seguimiento, la ablación no se consideró sustitutiva, sino complementaria del desfibrilador implantable (AU)

Introduction and objectives. The frequent occurrence of ventricular tachycardia can be a serious problem for patients with an implantable defibrillator, and may necessitate adjuvant antiarrhythmic therapy or radiofrequency catheter ablation. We analyzed the long-term results obtained with this latter therapy in patients suffering from frequent or continuous ventricular tachycardia. Patients and method. Eighteen ablation procedures were performed in 11 patients who had a defibrillator implanted because of previous syncopal ventricular tachycardia. All were men, aged 67.64 (5.87) years; 10 patients had had a myocardial infarction 15.50 (5.08) years earlier, and one suffered from arrhythmogenic right ventricular dysplasia. Results. Electrophysiologically, treatment was initially successful in 8 patients (72.73%). After a follow-up period of 39.10 (24.70) months, the number of defibrillator discharges decreased significantly in all patients, from 52.82(35.73) to 0.64 (1.03) (P=.001). During follow-up, ventricular tachycardia occurred in nine patients. In five, it took the same form as the ablated ventricular tachycardia. Six patients needed additional ablation procedures: two because of initial failure, three because of recurrence, and one because a different ventricular tachycardia occurred. In addition to the good electrophysiological results obtained, long-term clinical evolution was favorable in all patients. Conclusions. Radiofrequency ablation successfully disrupts frequent or continuous ventricular tachycardias and significantly reduces the defibrillator discharge rate even when ablation has failed electrophysiologically. It is particularly useful in these latter critical situations, in which other therapies are not sufficiently effective. Because our patients mainly had ischemic heart disease and were highly susceptible to new arrhythmias during follow up, ablation complemented rather than replaced the implantable defibrillator (AU)

Miocardiopatía hipertrófica y endocarditis: de la recomendación de profilaxis a su puesta en práctica / Prophylaxis for hypertrophic cardiomyopathy and infective endocarditis: from recommendations to implementation

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