[The postinfarct prognostic value of right ventricular systolic function]. / Valor pronóstico postinfarto de la función sistólica ventricular derecha.

BACKGROUND: Right ventricular extension of inferior myocardial infarction has been shown to be a predictor of poor prognosis during the acute phase. However, it is not known whether right ventricular dysfunction predicts long term complications. The aim of the present study was to assess whether right ventricular ejection fraction is also a predictor of poor prognosis during the first five follow-up years. METHODS: Ninety-eight consecutive patients (age < or = 65 years) with acute noncomplicated myocardial infarction (49 anterior and 49 inferior) were evaluated before hospital discharge. In all of them the ejection fraction of both ventricles was evaluated with radionuclide ventriculography at rest and during submaximal exercise. All patients were clinically followed up for at least 5 years. The prognostic relevance of right and left ventricular function for the prediction of all complications and severe complications was assessed using univariate and multivariate analysis. RESULTS: After 5 years, 66 patients had 94 complications (angina in 44, heart failure in 21, reinfarction in 10, revascularization procedures in 11, death in 6). In the univariate analysis, resting right ventricular ejection fraction was significantly lower in patients with inferior infarction and severe complications at one year (32 +/- 12% vs 38 +/- 6%, p = 0.03). However, in multivariate analysis only resting left ventricular ejection fraction was predictive of complications at 5 years (odds ratio 5.93, 95% confidence interval = 1.32-26.6). Statistical results did not change when the ejection fraction of both ventricles during submaximal exercise was considered. CONCLUSIONS: Although right ventricular ejection fraction, measured before hospital discharge, is predictive of complications at five years in inferior infarctions, multivariate analysis shows that it does not add prognostic information to the measurement of left ventricular ejection fraction in patients with uncomplicated acute myocardial infarction, either anterior or inferior.

[The diagnosis of ventricular pseudoaneurysms. The complementary role of echocardiography, isotopic ventriculography and contrast ventriculography]. / Diagnóstico de los seudoaneurismas ventriculares. Papel complementario de la ecocardiografía, la ventriculografía isotópica y la ventriculografía de contraste.

The diagnostic yield of echocardiography, radionuclide ventriculography (first pass and multiple gated) and contrast ventriculography was evaluated in 11 patients in whom a diagnosis of left ventricular pseudoaneurysm had been made during the last ten years. The diagnosis was made by two dimensional echocardiography (associated with Doppler in the last 5 patients) in 8 of 11 patients (sensitivity: 73%). The major limitation of the technique, in addition to the impossibility of an adequate recording due to a suboptimal acoustic window, is the poor definition of the neck of the pseudoaneurysm, particularly in the inferior localization. By contrast, echocardiography is the only technique which permits the direct visualization of thrombi within the pseudoaneurysm. Multiple gated radionuclide ventriculography was diagnostic in 7 of 10 patients (sensitivity: 70%). Its major limitations are the poorer spatial resolution to visualize the pseudoaneurysm neck and the thrombi within the cavity. First pass radionuclide ventriculography was diagnostic in 4 of 6 patients (sensitivity: 67%). In one of them it improved on the diagnostic yield of the multiple gated technique. Contrast ventriculography was diagnostic in 5 of 7 patients (sensitivity: 71%). The diagnosis was missed due to technical problems in one patient and to significant thrombosis within the pseudoaneurysm in another. Thus, none of the imaging studies has optimal sensitivity. Therefore, all play a complementary role in the diagnosis of ventricular pseudoaneurysm.

Uncomplicated first myocardial infarction: strategy for comprehensive prognostic studies.

To evaluate the prognostic role of combined cardiac studies (submaximal exercise test, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, Holter monitoring and cardiac catheterization) in patients with a first acute myocardial infarction without complications during hospital admission, 115 consecutive patients aged less than 65 years were prospectively evaluated. The studies were carried out before hospital discharge and the patients were then clinically followed up for 12 months. During the follow-up period, 69 patients (60%) developed complications, which were severe in 23 (20%). Half of all complications and 70% of severe complications developed during the 1st follow-up month. Logistic regression analysis disclosed that the combination of studies with the highest predictive power for complications (probability of complications 99%) and severe complications (probability of severe complications 95%) was the association of exercise test + thallium-201 + echocardiogram. Four decision models (exercise test + echocardiography, exercise test + radionuclide ventriculography, thallium-201 scintigraphy + echocardiography, thallium-201 scintigraphy + radionuclide ventriculography) allowed the stratification of all patients in a particular risk category (high, intermediate or low). The best decision model was the association of thallium-201 scintigraphy + radionuclide ventriculography (probability of complications if both tests were positive 84%; probability of absence of severe complications if both tests were negative 88%), but there were no significant differences with the other models. Any association of a test detecting residual ischemia or functional capacity, or both (exercise test or thallium-201) and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in significant prognostic information in patients with an uncomplicated first acute myocardial infarction. Additional cardiac catheterization does not improve the predictive power of noninvasive studies, which should ideally be performed before hospital discharge because most complications develop during the 1st follow-up month.

Late prosthetic valve endocarditis.

A report is given of 13 patients with late prosthetic valve endocarditis (1975-1982). Follow-up ranged from 1 to 8 years (mean 33 months). Causative organisms were streptococci in 8 cases, staphylococci in 2, and Cardiobacterium hominis in 1. Cultures were negative in 2. Surgical treatment in the acute phase was performed in 3 patients. At the latest clinical control, 3 patients had died and 10 patients were asymptomatic, 3 of them having required late operation. These fair results are attributable to the particular spectrum of causative organisms and to the proper timing of surgical treatment in the 3 patients operated during the acute phase.