Transcatheter closure of paravalvular leaks: state of the art.

Paravalvular leak (PVL) is a serious complication after surgical valve replacement or after transcatheter aortic valve replacement. Approximately 1-5% of PVLs can lead to serious clinical consequences, including congestive heart failure and/or haemolytic anaemia. For years, surgical re-intervention has been considered the treatment of choice for symptomatic patients with PVLs. However, surgical re-intervention is associated with a high risk of morbidity and mortality. Transcatheter PVL (TPVL) closure is a less invasive alternative to surgical re-intervention. The safety and feasibility of TPVL closure has been confirmed in several registries and a meta-analysis.In this review, we discuss the clinical implications and diagnosis of PVLs, technical considerations for TPVL, execution of the procedure and assessment of the results.

[Appraisal of the state of the autonomic nervous system in hypertrophic cardiomyopathy by the analysis of heart rate variability]. / Aproximación al conocimiento del estado del sistema nervioso autónomo en la miocardiopatía hipertrófica mediante el análisis de la variabilidad de la frecuencia cardíaca.

INTRODUCTION: The analysis of heart rate variability has been accepted as a non-invasive method to evaluate the influence of the autonomic nervous system over the heart. Although heart rate variability has been used during the last decade in several illnesses the studies in hypertrophic cardiomyopathy are scarce. OBJECTIVES: We report the activity of the autonomic nervous system in patients with hypertrophic cardiomyopathy using the analysis of heart rate variability. PATIENTS AND METHODS: Heart rate variability was evaluate by the analyzing 24-h ambulatory electrocardiograms (Holter) in 20 patients with hypertrophic cardiomyopathy and in 15 controls. This method has been used to measure heart rate variability. Spectral analysis of the frequencies were calculated using fast Fourier transformation. Spectral heart rate variability was computed as high (0.15 to 0.40 Hz) low (0.04 to 0.15 Hz) and total (0.01 to 1.0 Hz). We compared the relation between low/high frequency as an index of the sympathetic/parasympathetic balance. All data are expressed as mean value +/- SD. The unpaired Student t-test was used. A two tailed p valued < 0.05 was considered statistically significant. RESULTS: There were no differences in the mean heart rates among the patients with hypertrophic cardiomyopathy and normal subjects (mean +/- SD: 71 +/- 9 versus 74 +/- 11 beats/minute; p = NS) while there was a significant decline in total spectral (mean +/- SD: 7.14 +/- 1.1 versus 7.57 +/- 0.6 ln [ms2]; p = 0.02) and high (mean +/- SD: 5.22 +/- 0.8 versus 5.63 +/- 1.3 ln [ms2]; p = 0.04) as well as in low spectral frequency of heart rate variability (mean +/- SD: 22 +/- 0.8 versus 5.63 +/- 1.3 ln [ms2]; p = 0.04) in patients with hypertrophic cardiomyopathy. There were no differences in the low/high frequency component ratio in these patients (mean +/- SD: 1.1 +/- 0.1 versus 1.2 +/- 0.1 ln [ms2]; p = NS). CONCLUSIONS: These facts suggest that the patients with hypertrophic cardiomyopathy have an alteration in the autonomic nervous system: sympathetic (low spectral frequencies) and parasympathetic activity (high spectral frequencies), although this does not reflect an imbalance between sympathetic and parasympathetic activities (relation of low to high spectral frequencies).

[Cardiomyopathy (X). Clinical approach to the patient with hypertrophic cardiomyopathy]. / Miocardiopatías (X). Actitud clínica ante el paciente con miocardiopatía hipertrófica.

Hypertrophic cardiomyopathy is a clinical and anatomofunctional entity that determines a series of hemodynamic consequences closely related to sintomatology. Left ventricular hypertrophic, subaortic stenosis, diastolic dysfunction and myocardial ischemia are the different pathophysiology mechanisms that generate similar clinical manifestations. Sintomatology defines two groups of patients with different profiles and clinical management. Ventricular arrhythmias are not uncommon and the forms that imply a darkest prognosis are supported symptomatic ventricular tachycardia and the induced ventricular tachycardia in patients that have suffered a cardiac arrest or have had syncopes. Basic explorations in all patients, in addition to physical examination, chest radiography and rest electrocardiogram, are Doppler echocardiography and Holter. Other explorations, such as Tallium-201 stress test, tilt test, electrophysiological and hemodynamic studies, are rationalized according to risk profile, sintomatology and responses to indicated treatment. In general, prognosis in asymptomatic patients is good and complex explorations are not justified nor are preventive character treatments. Symptomatic patients who have a higher risk must be studied more closely, and frequently require complex and invasive explorations. They also need pharmacological treatment and often more invasive therapeutical options, DDD pacemakers or surgery, if those fail.

[Study of heart rate variability in acute myocardial infarction and its relationship with ventricular function and other clinical variables]. / Estudio de la variabilidad de la frecuencia cardíaca en el infarto agudo de miocardio y su relación con la función ventricular y otras variables clínicas.

BACKGROUND: The influence of ventricular function (VF) on prognosis in acute myocardial infarction (AMI) is well known. Heart rate variability (HRV), as a neurohumoral parameter could predict VF after discharge in AMI patients. Our goal is to investigate the possible relation among HRV, VF and another clinical variables in AMI. PATIENTS AND METHODS: We studied 37 patients with AMI after hospital discharge. Age, AMI type, location, enzymes, treatment (thrombolysis versus no thrombolysis) were evaluated. The left ventricular ejection fraction (LVEF) was assessed by radionuclide ventriculography in 27 subjects. Twenty nine subjects without cardiopathy were the control group. Twenty four hour electrocardiographic recordings were obtained and a proper software was used to measure HRV. This was evaluated with time domain measures: RR interval, standard deviation of the mean RR interval (SDNN), standard deviation of the average of the RR intervals measured every 5 minutes during 24 hours (SDANN) and number of two consecutive RR intervals with a variability > 50 ms (pNN50). We considered a decreased variability if SDANN was less than 100 ms. Two groups were established: 1) low heart rate variability (LHRV) if SDANN was less than 100 ms, and 2) normal heart rate variability (NHRV) if SDANN was larger than 100 ms. Continuous variables were examined by the t-test, chi square for discrete ones and linear regression analysis was used to assess the relation among variables. A p < 0.05 was considered significant. RESULTS: The percentage of infarcted patients in the group of LHRV is 75%, whereas it is 14% in the control group (p < 0.05). SDANN, SDNN and pNN50 values are significantly lower (p < 0.05) in the AMI than in the control group. LHRV was more frequent in patients with complicated AMI with congestive heart failure. LVEF was significantly lower (35% vs 56%) in the LHRV than in the NHRV group. No significant differences were found among: site, type infarct, treatment or ventricular ectopy in the Holter before discharge. There is good correlation (r = 0.635; p < 0.05) between LVEF and HRV measures. No correlation was found between HRV and age, or the enzymatic size of infarction. CONCLUSIONS: 1) LHRV is frequent in the late phase of AMI, and 2) LHRV can be an indirect index of left ventricular failure.

Total anomalous pulmonary venous connection in adults. Long-term follow-up.

Between 1961 and 1989, 19 patients with total anomalous pulmonary venous connection underwent surgical correction. Ages ranged from 18 to 38 years (mean 26.2 +/- 6.5 years). The anatomic variants included 10 patients with total anomalous pulmonary venous connection to the vertical vein, 6 patients with total anomalous pulmonary venous connection to the coronary sinus, and 2 with total anomalous pulmonary venous connection directly to the right atrium. The last patient had mixed connection to the coronary sinus and left vertical vein. Two patients died, one because of left atrial rupture and another of low cardiac output. Long-term follow-up after surgical repair ranged from 2 to 24 years (mean 7 +/- 6.2 standard deviation). Preoperative disability, assessed according to New York Heart Association criteria, showed 12 patients in functional class II and seven in class III. After treatment, 16 patients were in class I and one in class II (p less than 0.001). Echocardiographic evaluation of six patients revealed in all a normal left ventricular ejection fraction; the diastolic function was also normal except in one patient. The postoperative evaluation of the pulmonary arterial systolic pressure performed by both Doppler echocardiography and right cardiac catheterization in 14 patients showed a significant reduction of the mean pulmonary arterial systolic pressure from 51.1 +/- 3.4 to 37.4 +/- 14.4 mm Hg (p less than 0.01). The remaining three patients evaluated in the follow-up period only by clinical examination are in New York Heart Association functional class I. The anatomic characteristics of our patients were responsible for the long-term outcome without correction. Surgical treatment of older patients can be performed with satisfactory results and excellent long-term survival.