[Echocardiographic indicators of electric cardioversion in patients with atrial fibrillation]. / Indicadores ecocardiográficos de cardioversión eléctrica en pacientes con fibrilación auricular.

We studied 80 patients to evaluate the safety of the transesophageal echocardiography (TEE) as a guidance to identify spontaneous echo contrast or atrial thrombosis in patients with atrial fibrillation (AF). 34 out of these patients were men and 46 women, with a mean age of 61 +/- 12 years. Five were not candidates due to the presence of risk factors. 75 patients have undergone electric cardioversion. The duration of AF was < 2 weeks in 61 > or = 2 and < 6 weeks 13, and > or = 6 weeks and < 1 year 6; 24 patients received previous anticoagulant therapy. The echocardiographic findings revealed left atrial dimension 45 +/- 8.4 mm ejection fraction of left ventricle 61 +/- 7.5%, SEC absent in the left atrium of 35, mild in 40 and severe in 5 patients, flow in left atrial appendage in 78 patients, thrombi in 2. EC was performed with 200 Joules in all patients and it was successful in 74. The study lasted 8.7 +/- 5.7 months; 11 patients were recurrent. The predictors were: left atrial dimension > 50 mm (p > 0.05), > 2 EC performed (p = 0.02), > 200 Joules (p = 0.05) and in patients with AF < or = 2 weeks. We concluded that the TEE is beneficial to detect risk factors in patients with AF, and it helps when deciding to perform the EC early and safely without previous anticoagulation.

High dose and short-term streptokinase infusion in patients with pulmonary embolism: prospective with seven-year follow-up trial.

BACKGROUND: High dose and short-term streptokinase infusion has proved to improve survival among few patients with pulmonary embolism and cardiogenic shock, without increasing hemorrhagic complications. However its efficacy and safety in terms of long follow-up and in major number of patients requires to be established. METHODS: Patients with pulmonary embolism proved through high probability V/Q lung scan, suggestive echocardiogram, or deep venous thrombosis were enrolled. All were assigned to receive 1,500,000 IU in one-hour streptokinase infusion. The primary end point was efficacy and safety of streptokinase regimen in terms of pulmonary arterial hypertension, right ventricular dysfunction, perfusion abnormalities, recurrence, mortality and hemorrhagic complications. In long-term follow-up, we assessed functional class, recurrence, chronic pulmonary arterial hypertension, postthrombotic-syndrome and mortality. RESULTS: A total of 40 consecutive patients (47.3+/-15.3 years of age) with large or massive pulmonary embolism were enrolled. In 35 patients high dose and short-term streptokinase regimen reversed acute pulmonary arterial hypertension, clinical and echocardiographic evidence of right ventricular dysfunction and improved pulmonary perfusion without increasing hemorrhagic complications. In acute phase 5 patients died, necropsy study performed in 4 patients showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. Risk factors for mortality and recurrence were: right ventricular global hypokinesis (p<0.0001), 6 hours or over between onset symptoms and streptokinase regimen (p=0.02), severe systolic pulmonary arterial hypertension (p=0.001) right ventricular hypokinesis (p=0.001), hypoxemia (p=0.02) and right ventricular acute myocardial infarction (p<0.0001). Right ventricular hypokinesis (p=0.02) was the only independent risk factor for recurrence. In a seven-year follow-up of the original 35 patients who survived in acute phase, 2 patients were lost and 33 are alive, in functional class I, without recurrence or chronic pulmonary arterial hypertension. CONCLUSIONS: Our report indicates that among properly selected high-risk PE patients, short-term streptokinase infusion is effective and safe.

[Medical-surgical management of left heart valve prosthesis dysfunction due to obstruction. Eleven year's experience]. / Manejo médico-quirúrgico en la disfunción de prótesis valvular mecánica cardiaca izquierda por obstrucción. Once años de experiencia.

UNLABELLED: We report the surgical-medical experience in left side mechanic prosthesis cardiac valve dysfunction. From January 1986 to June 1997 we included 108 consecutive patients (pts), 24 were men and 84 women, mean age 45 years, they underwent 114 surgical procedures, 104 in mitral and 10 in aortic position. RESULTS: The dysfunction was due to obstruction in fixed disc in 107 pts and intermitent in 7 pts. The pathological findings were thrombosis in 92 pts, pannus in 9 pts and both in 13 pts. The time interval between valve replacement and dysfunction was from 1 to 247 months, mean 53.8 +/- 56.7. Seventy five percent of patients received inadequate anticoagulant therapy, the mean INR was 2.06 +/- 0.79. In 76% of patients the functional class was III or IV NYHA. The diagnosis was made by clinical and echocardiographic findings in 96% of patients. The surgical procedures included valve replacement in 103, and toilette in 11 pts. The time of extracorporeal circulation in patients who died us survival patients were (159.9 +/- 108.95 vs 87.32 +/- 27.53 min) and aortic cross-clamp (64.8 +/- 20.69 vs 48.28 +/- 23.71 min) respectively (p < 0.001). The overall mortality was 12 pts (10.5%), all in functional class III or IV NYHA (p < 0.05), five patients died during surgical procedure. In conclusion the diagnosis must be established clinically as well as by echocardiography. The risk factors associated with mortality were pulmonary edema, shock, delayed surgery, surgical time prolonged and functional class III or IV NYHA.

[Preoperative evaluation of severe aortic stenosis by Doppler echocardiography and hemodynamics]. / Valoracíon preoperatoria de la estenosis aórtica grave por ecocardiografía-Doppler y hemodinámica.

UNLABELLED: Several diagnostic tools have been used in the evaluation of the severity transvalvular gradient and aortic valve area. The advances in cardiac catheterization and Doppler echocardiographic measure these items accurately. We designed a retrospective, observational open and transversal survey that included patients with severe aortic stenosis that required transseptal cardiac catheterization. Their echocardiographic and hemodynamic studies were reviewed. From January 1991 to December 1996 we studied 30 patient from a population of 256. All of them with severe aortic stenosis. There were 17 males and 13 females with an age range from 32 a 71 years. RESULTS: the transvalvular gradient measured by catheterization vs. Doppler echocardiogram was 98.80 +/- 37.29 mmHg vs. 96.63 +/- 38.64 mmHg respectively P = 0.84. The valvular area measured by catheterization vs Doppler echocardiographic 0.63 +/- 0.17 cm2 vs 0.62 +/- 0.15 cm2 respectively P = 0.63. There was not difference in the gradients using these two methods. We conclude that patients with severe aortic stenosis could be referred to surgical procedure without the need of cardiac catheterization if no concurrent coronary disease is suspected.

[Thrombolysis in unstable angina. A perspective before and after TIMI IIIB]. / Trombolisis en angina inestable. Una perspectiva antes y después del TIMI IIIB.

To identify the utility and security of thrombolytic therapy in unstable angina, we performed: a) retrospective analysis of controlled trials through computers system and cross references; b) analysis of TIMI IIIB trial to identify variables that explain, why thrombolytic therapy was unsuccessful; c) analysis of our clinical experience. For the three models of research, variables of primary and secondary effectivity were designed. Twenty two controlled trials with 3,544 patients were analyzed, the variables of primary effectivity suggest that in patients with unstable angina with sustained and recurrent clinical and electrocardiographic manifestations of acute ischemia, the use thrombolytic therapy could produce benefit, if the main mechanism is an intracoronary thrombus and if it is associated with maximum pharmacologic treatment and anticoagulation in acute phase. In the TIMI IIIB trial, variables that explain unsuccessful thrombolytic therapy were identified. The clinical experience in 17 patients with high risk unstable angina that received streptokinase in accelerated and standard infusion, proved success in 100% of the cases by improvement of ischemia, avoidance of infarction and recurrence, without hemorrhagic complications, without mortality. The results suggest, that in unstable angina with high clinical suspicion of disruption and thrombogenesis, refractory acute ischemia, jeopardized myocardium, and hemodynamic unstability, thrombolytic therapy could be an alternative that eliminates acute ischemia, as a bridge to the use in a second time of a definitive therapy. These data require in our environment revalidation with controlled trials and inclusion of more patients.

[Rescue thrombolysis with repeated doses of streptokinase in acute myocardial infarct. A preliminary report]. / Trombolisis de rescate con dosis repetidas de estreptoquinasa en el infarto agudo del miocardio. Reporte preliminar.

In patients with persistent acute ischemia and early reocclusion after thrombolytic therapy, the available therapeutic options are optimum drug pharmacologic treatment or a mechanical revascularization. Recently, repeated doses of the same thrombolytic agent used (rescue thrombolysis) have been considered. We report our experience in seven patients with acute myocardial infarction treated with conventional streptokinase dose, within the first 6 hs after onset of the symptoms, and whom due to persistent myocardial ischemia or early reocclusion, hemodynamic instability, significative area of myocardium at risk, failure of maximal doses of conventional therapeutic and inaccessibility for performed mechanical revascularization, a second dose of streptokinase was successfully employed in the early (1:45 to 2:30 hs) and late (48 to 50:00 hs) phase, without hemorrhagic complications and without hypersensitivity effects. In every case rescue thrombolysis allowed to limit the time of ischemia and the extension of the myocardial infarction, demonstrated by indirect clinical criteria, improvement in hemodynamic instability and in the ventricular ejection fraction, that can be considered as a postinfarction myocardial function index, as well as by the reduced in-hospital mortality. These findings suggest that in patients with acute myocardial infarction treated with thrombolytic therapy, and persistent acute ischemia or early reocclusion, a second dose of streptokinase could be a safe and effective therapeutic option. Our successful results will lead to a prospective trial.

Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism: A Randomized Controlled Trial.

To test the efficacy of thrombolytic therapy in massive pulmonary embolism, we conducted a prospective randomized controlled trial. Eight patients were randomized to receive either 1,500,000 IU of streptokinase in 1 hour through a peripheral vein followed by heparin or heparin alone. All patients had major risk factors for deep vein thrombosis (DVT) and were considered to have high clinical suspicion for pulmonary embolism (PE). At baseline all patients had a similar degree of systemic arterial hypotension, pulmonary arterial hypertension, and right ventricular dysfunction. The time of onset of cardiogenic shock in both groups was comparable (2.25 +/- 0.5 hours in the streptokinase group and 1.75 +/- 0.96 hours in the heparin group). The four patients who were randomized to streptokinase improved in the first hour after treatment, survived, and in 2 years of follow-up are without pulmonary arterial hypertension. All four patients treated with heparin alone died from 1 to 3 hours after arrival at the emergency room (p = 0.02). Post-thrombolytic therapy the diagnosis of PE was sustained in the streptokinase group by high probability V/Q lung scans and proven DVT. A necropsy study performed in three patients in the heparin group showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. The results indicate that thrombolytic therapy reduces the mortality rate of massive acute pulmonary embolism.

[High doses and the rapid infusion of streptokinase for the treatment of massive pulmonary thromboembolism]. / Dosis altas e infusión rápida de estreptoquinasa para el tratamiento de tromboembolia pulmonar masiva.

We report the case of a 65 year old woman with no prior cardiac or pulmonary disease, who suffered pulmonary embolism (PE); diagnosis was made on the basis of the existence of risk factors, clinical, radiographic and electrocardiographic features, and a lung scan with perfusion defects and normal ventilation. PE was considered massive because the patient developed acute respiratory failure that required tracheal intubation and mechanical ventilation as well as obstructive shock, electrocardiographic and echocardiographic data of right ventricle overload, and pulmonary hypertension, with pulmonary artery pressure of 38 mmHg. She received an initial treatment with high doses (1,500,000 UI) and rapid infusion (1 hr) of intravenous streptokinase (SK) followed by heparin anticoagulation. Thereafter the hemodynamic disturbances improved and pulmonary artery pressure post-thrombolysis was 23 mmHg. In this report SK at high doses and rapid infusion showed effectiveness and security. We emphasize the usefulness of echocardiography as a diagnostic aid in patients with a previously healthy cardiopulmonary system, as well as the possible role of electrocardiogram as an early indicator of pulmonary reperfusion. This could be the first report of successful thrombolysis with high doses and rapid infusion of SK in massive PE.