Cierre de apéndice auricular en fibrilación auricular y alto riesgo de sangrado: serie de casos / Atrial appendage closure in atrial fibrillation and high risk of bleeding: case series

RESUMEN INTRODUCCIÓN: La fibrilación auricular aumenta 5 veces el riesgo de un ataque cerebrovascular de origen cardioembólico. La anticoagulación está indicada para prevención primaria y secundaria de embolismo cerebral. En pacientes con alto riesgo de sangrado no modificable se ha propuesto el cierre de apéndice auricular izquierdo como alternativa a la anticoagulación. MÉTODOS: Serie de casos retrospectiva de pacientes incluidos en el registro ReACTIVE entre los años 2019 y 2020 con diagnóstico de fibrilación auricular, puntaje de CHA2DS2-VASc ≥ 4, HAS BLED ≥ 3 y contraindicación de terapia anticoagulante a largo plazo. Se incluyeron variables demográficas, factores de riesgo, desenlace clínico usando la escala de Rankin modificado y se hizo seguimiento clínico a 3 meses después del procedimiento. RESULTADOS: Se incluyeron 6 pacientes, el 50 % de ellos mujeres, con mediana de edad de 80,8 ± 4,8 años. El 83,3 % presentó antecedente de sangrado mayor bajo consumo de anticoagulantes. En el seguimiento a 90 días, ningún paciente experimentó sangrado ni ataque cerebrovascular, un paciente murió por causas no cardiovasculares, en tanto que el 83,3 % de los pacientes tuvieron un Rankin modificado favorable (0-2). CONCLUSIONES: El cierre de apéndice auricular es una opción terapéutica en pacientes con fibrilación auricular y contraindicación para anticoagulación por alto riesgo de sangrado. Nuestra serie obtuvo resultados similares a los publicados a escala nacional a pesar de incluir pacientes con edad más avanzada. La conformación de equipos interdisciplinarios de corazón y cerebro es útil en la selección de pacientes para esta terapia.

ABSTRACT INTRODUCTION: Atrial fibrillation increases the risk of a cerebrovascular attack of cardioembolic source by 5 times. Anticoagulation is indicated for primary and secondary prevention of cerebral embolism. In patients at high risk of non-modifiable bleeding, closure of the left atrial appendage has been proposed as an alternative to anticoagulation. METHODS: Retrospective case series of patients included in the ReACTIVE registry between 2019 and 2020 with a diagnosis of atrial fibrillation, CHA2DS2-VASc score ≥ 4, HAS-BLED ≥ 3, and long-term anticoagulant therapy contraindication. Demographic variables, risk factors, and clinical outcomes were included using the modified Rankin scale, and clinical follow-up was done three months after the procedure. RESULTS: 6 patients were included, 50 % women, median age 80.8 ± 4.8 years. 83.3 % history of major bleeding under anticoagulant treatment. At the 90-day follow-up, no patient had a bleeding or cerebrovascular attack, one patient died from non-cardiovascular causes, and 83.3 % of the patients had a favorable modified Rankin (0-2). CONCLUSIONS: Atrial appendix closure is a therapeutic option in patients with atrial fibrillation and a contraindication for anticoagulation due to a high risk of bleeding. Our series obtained results like those published at the national level despite including older patients. The formation of interdisciplinary heart and brain teams is helpful in the selection of patients for this therapy.

Benefits of Cardiac Rehabilitation on Functional Status and Mood Disorders in Elderly and Very Elderly Patients: A PROSPECTIVE COHORT STUDY.

PURPOSE: Patients ≥80 yr are not frequently referred for cardiac rehabilitation (CR). This study aimed to describe the benefit of CR in the very elderly population in comparison with patients ≤65 and 66-79 yr in terms of gain in functional status and improvement of mood disorders. METHODS: We conducted a prospective, cohort, single-center study. Physical performance was evaluated with a 6-min walk test (6MWT). Anxiety, depression, and overall psychological distress were evaluated with Hospital Anxiety and Depression Scale (HADS) scores. Primary outcomes were the percent improvement in the predicted distance and the reduction in the prevalence of anxiety, depression, and overall psychological distress. RESULTS: There were 45 (9%) patients ≥80 yr among 499 participants. There were no significant differences in the percent improvement of the predicted distance in the 6MWT among age groups, being +15 (7, 25)%, +15 (7, 25)%, and +10 (4, 26)% for ≤65, 66-79, and ≥80-yr groups, respectively (P = .11). The elderly group had a higher prevalence of depression, anxiety, and overall psychological distress (72%, 51%, and 38%, respectively). After CR, there was a significant improvement in HADS scores in all groups. The prevalence of depression was reduced by 38%, anxiety by 60%, and overall psychological distress by 58%. CONCLUSION: Patients ≥80 yr have decreased physical performance and a higher prevalence of mood disorders than their younger counterparts. Nevertheless, they improved significantly in all outcomes measured.

Supervivencia a 30 días y 1 año de pacientes con muerte súbita con posterior colocación de dispositivo cardíaco implantable en un hospital de alta complejidad / Patients with sudden cardiac death receiving an implantable cardiac device: survival at 30 days and one year

Background: The use of implantable cardiac devices in patients with sudden cardiac arrest has contributed to their survival. Aim: To determine the survival rate at 30 days and one year after hospital discharge of patients who had a cardiac arrest with subsequent placement of an implantable cardiac device. Material and Methods: Twenty-three patients older than 18 years who presented sudden extra-institutional or intra-institutional death with subsequent implantation of an implantable cardiac device and whose survival was recorded at 30 days and one year, were included. A univariate analysis was performed. Results: Eighteen patients had an extra institutional cardiac arrest. All patients were discharged alive. We could not ascertain the health status of one patient at follow-up. Twenty-one patients had a Cerebral Performance Category (CPC) of 1 at discharge. One patient died of a stroke within 30 days and one patient died due to an arrhythmic electrical storm one year later. Twenty patients survived at least one year after hospital discharge. Conclusions: Survival at 30 days and one year, was high in patients with sudden death or cardiac arrest who required intracardiac devices.

[Patients with sudden cardiac death receiving an implantable cardiac device: survival at 30 days and one year]. / Supervivencia a 30 días y 1 año de pacientes con muerte súbita con posterior colocación de dispositivo cardíaco implantable en un hospital de alta complejidad.

BACKGROUND: The use of implantable cardiac devices in patients with sudden cardiac arrest has contributed to their survival. AIM: To determine the survival rate at 30 days and one year after hospital discharge of patients who had a cardiac arrest with subsequent placement of an implantable cardiac device. MATERIAL AND METHODS: Twenty-three patients older than 18 years who presented sudden extra-institutional or intra-institutional death with subsequent implantation of an implantable cardiac device and whose survival was recorded at 30 days and one year, were included. A univariate analysis was performed. RESULTS: Eighteen patients had an extra institutional cardiac arrest. All patients were discharged alive. We could not ascertain the health status of one patient at follow-up. Twenty-one patients had a Cerebral Performance Category (CPC) of 1 at discharge. One patient died of a stroke within 30 days and one patient died due to an arrhythmic electrical storm one year later. Twenty patients survived at least one year after hospital discharge. CONCLUSIONS: Survival at 30 days and one year, was high in patients with sudden death or cardiac arrest who required intracardiac devices.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias.

Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 ± 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 ± 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias / Denervación simpática cardíaca en arritmias refractarias al tratamiento convencional

Abstract Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 � 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Resumen Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 +- 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias.

Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 ± 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 ± 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias.

BACKGROUND: Differential diagnosis of wide QRS complex tachycardias using the 12-lead ECG may be difficult in many clinical settings. OBJECTIVE: The purpose of this study was to determine the value of ECG lead II, specifically, the duration at its beginning, defined as R-wave peak time (RWPT), in differentiating ventricular tachycardia (VT) from supraventricular tachycardia (SVT) in patients with wide QRS complex tachycardia. METHODS: Two hundred eighteen ECGs showing wide QRS complex tachycardias were evaluated. Two cardiologists blinded to the diagnosis measured RWPT duration at lead II (from the isoelectric line to the point of first change in polarity), and results between VT and SVT were compared, with the findings of electrophysiologic study used as the gold standard. RESULTS: One hundred sixty-three VTs had a significantly longer RWPT at DII (76.7 +/- 21.7 ms vs 26.8 +/- 9.5 ms in 55 SVT, P = .00001). Receiver operating characteristic curve identified RWPT > or =50 ms at lead II as having greater specificity and sensitivity in discriminating VT from SVT. Area under the curve was 0.97 (95% confidence interval 0.95-0.99), positive likelihood ratio was 34.8, and kappa coefficient (kappa) was 0.86. Bivariate analysis identified higher age in VT patients (60.7 vs 50.1 years, P < or =.01) and wider QRS complex duration at lead II in VT patients (169.4 vs 128.3 ms, P <.0001). QRS width at DII was not superior to RWPT in diagnosing VT. CONCLUSION: RWPT > or =50 ms at DII is a simple and highly sensitive criterion that discriminates VT from SVT in patients with wide QRS complex tachycardia.

Characterization of focal right atrial appendage tachycardia.

AIMS: Though right atrial appendage tachycardia (RAAT) has been described, no studies to date have focused on its clinical characterization. The aim of the present study was to analyze its clinical, electrocardiographic (ECG), and electrophysiologic (EP) characteristics and the results of radiofrequency ablation (RFA) in RAAT. METHODS AND RESULTS: Out of 186 consecutive patients undergoing RFA for AT, 15 (8%) had focal RAAT. Mapping was performed using conventional catheters or a 3D electroanatomic mapping system. Patients with RAAT were more likely to be male (66 vs. 38%; P= 0.013) and younger (32 +/- 12.6 vs. 55 +/- 13.2 years; P < 0.001) than patients with AT originating elsewhere. They were also more likely to have dyspnea (27 vs. 7.6%; P = 0.03), incessant tachycardia (53 vs. 16%; P < 0.001), and left ventricular systolic dysfunction (27 vs. 5%; P = 0.018). RFA was effective in all patients (100 vs. 75%; P = 0.022) and no recurrences (0 vs. 8%; P = 0.31) were observed during a mean follow-up of 37 +/- 36 months. A specific ECG pattern was identified, consisting of negative P-waves in leads V1-V2 and a transition to positivity in the rest of the precordial leads. This ECG pattern correctly identified RAAT with a sensitivity of 100%, a specificity of 98%, a positive predictive value of 88%, and a negative predictive value of 100%. CONCLUSION: Right atrial appendage tachycardia is more prevalent in young male patients and is commonly associated with tachycardiomyopathy. RFA is effective over long-term follow-up. A characteristic ECG pattern identifies RAAT with a very high sensitivity and specificity.

Isquemia miocárdica y prolongación del intervalo QT / Myocardial ischemia and QT interval prolongation

La prolongación anormal del intervalo QT tiene relevancia por su asociación con inestabilidad eléctrica ventricular, pudiéndose presentar arritmias ventriculares polimórficas en "puntas torcidas". Los síntomas acompañantes de estas arritmias son el síncope, convulsiones o la muerte súbita. Se puede clasificar en síndrome de QT prolongado congénito, el cual se hereda o lo adquiere el individuo de manera esporádica y el síndrome adquirido que se puede presentar asociado a fármacos u otras situaciones clínicas. Presentamos el caso de una mujer de 41 años de edad que desarrolló cambios típicos de síndrome de QT prolongado por isquemia miocárdica y hacemos una breve revisión.

Lupus inducido por medicamentos / Lupus by drugs

Se describe el caso de una paciente de 55 años quien consulta por un síndrome febril asociado a artralgias, y en cuyos exámenes relacionados con su estudio se encuentran unos ANAs positivos a títulos altos. Tenía como antecedente el uso de captopril por hipertensión arterial. Se sospecha la presencia de lupus inducido por medicamentos. El retiro de la medicación llevó a la resolución del cuadro clínico y paraclínico

Validación del indice pronóstico específico de neumonía (Indice de Fine) en neumonía adquirida en la comunidad en el Hospital Universitario del Valle (HUV), Cali - Colombia / Validation of the pneumonia specific pronostic index (Finens Index) in community acquired pneumonia at the hospital Universitario del Valle (HUV), Cali - Colombia

Objetivo: Validar el indice pronóstico específico de neumonía (índice de Fine), en los pacientes atendidos por neumonía adquirida en la comunidad (NAC). Tipo de estudio: Observacional analítico - Cohorte histórica. Pacientes y métodos: Pacientes mayores de 15 años con NAC, atendidos en el Hospital Universitario del Valle (HUV) entre 1993 y 1995. Se obtuvo información retrospectiva sobre el estado clínico del paciente al ingreso y su egreso. El índice clasifica alos pacientes en 5 clases de riesgo basados en los seis predictores clínicos de mortalidad del índice pronóstico de neumonía (índice de Fine). Cada paciente fue asignado a una clase de riesgo al obtener los valores de los seis predictores del índice. Se evaluó el comportamiento de los predictores de mortalidad en los pacientes del HUV, (Cohorte de validación) y se comparó con la cohorte original del estudio de Fine (cohorte de derivación), al igual que la mortalidad en cada una de las cinco clases de riesgo del índice. Resultados: Se estudiaron un total de 294 pacientes. En el análisis multivariado solo tres predictores de los seis del índice se asociaron independientemente con mortalidad: alteración del estado mental: OR=4.4 (IC95 porciento: 2.4 - 8.1), y dolor pleurítico: OR 0.3 (0.12 - 0.6). La mortalidad en las clases II, II y IV de riesgo fueron significativamente superiores a las pronosticadas por el índice. La mortalidad global fue también significativamente mayor que la de la cohorte original de Fine (25 porciento vs. 17 porciento p<0.01). Conclusión: El índice de Fine no predice adecuadamente la mortalidad en los pacientes con NAC, dado que la mortalidad observada fue mayor que la esperada por dicho índice. Es posible que los determinantes de mortalidad por NAC en nuestro medio sean diferentes

Avulsiones Traumáticas de la Pelvis y del Extremo proximal del Fémur

Se presentan tres casos de avulsiones traumáticas apofisiarias, localizadas a nivel de la pelvis y del extremo proximal del femúr. Dichas lesiones constituyen una patología poco común. Suelen pasar desapercibidas en un primer examen y no es infrecuente que su estudio radiográfico plantee problemas de diagnóstico diferencial, pues las imágenes observadas se interpretan como exostosis, miositis osificante e incluso tumores óseos. Es por ello que, deseando contribuir al esclarecimiento y precisión de esta particular patología, los autores hacen una revisión de la bibliografía existente haciendo una especial mención sobre su estudio radiográfico