Neurologists Preferences on Basic and Advanced Cardiac Imaging Utilization in Ischemic Stroke Patients.

INTRODUCTION: It is unknown how cardiac imaging studies are used by neurologists to investigate cardioembolic sources in ischemic stroke patients. METHODS: Between August 12, 2023, and December 8, 2023, we conducted an international survey among neurologists from Europe, North America, South America, and Asia, to investigate the frequency of utilization of cardiac imaging studies for the detection of cardioembolic sources of ischemic stroke. Questions were structured into deciles of percentage utilization of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), ECG-gated cardiac computed tomography (G-CCT), and cardiac magnetic resonance imaging (CMRI). We estimated the weighted proportion (x¯) of utilization of each cardiac imaging modality, both globally and by continent. We also investigated the use of head and neck computed tomography angiography (CTA) as an emerging approach to the screening of cardioembolic sources. RESULTS: A total of 402 neurologists from 64 countries completed the survey. Globally, TTE was the most frequently used cardiac imaging technology (x¯ = 71.2%), followed by TEE (x¯ = 15.8%), G-CCT (x¯ = 10.9%), and CMRI (x¯ = 7.7%). Findings were consistent across all continents. A total of 288 respondents routinely used a CTA in the acute ischemic stroke phase (71.6%), but the CTA included a non-gated CCT in only 15 cases (5.2%). CONCLUSIONS: This survey suggests that basic cardiac imaging is not done in all ischemic stroke patients evaluated in 4 continents. We also found a substantially low utilization of advanced cardiac imaging studies. Easier to adopt screening methods for cardioembolic sources of embolism are needed.

Clinical practice guideline for transcatheter versus surgical valve replacement in patients with severe aortic stenosis in Latin America.

In elderly (75 years or older) patients living in Latin America with severe symptomatic aortic stenosis candidates for transfemoral approach, the panel suggests the use of transcatheter aortic valve implant (TAVI) over surgical aortic valve replacement (SAVR). This is a conditional recommendation, based on moderate certainty in the evidence (⨁⨁⨁Ο).This recommendation does not apply to patients in which there is a standard of care, like TAVI for patients at very high risk for cardiac surgery or inoperable patients, or SAVR for non-elderly patients (eg, under 65 years old) at low risk for cardiac surgery. The suggested age threshold of 75 years old is based on judgement of limited available literature and should be used as a guide rather than a determinant threshold.The conditional nature of this recommendation means that the majority of patients in this situation would want a transfemoral TAVI over SAVR, but some may prefer SAVR. For clinicians, this means that they must be familiar with the evidence supporting this recommendation and help each patient to arrive at a management decision integrating a multidisciplinary team discussion (Heart Team), patient's values and preferences through shared decision-making, and available resources. Policymakers will require substantial debate and the involvement of various stakeholders to implement this recommendation.

Rationale and design of a multicenter, international and collaborative Coronary Artery Aneurysm Registry (CAAR).

Coronary artery aneurysm is defined as a coronary dilation that exceeds the diameter of adjacent segments or the diameter of the patient's largest normal coronary vessel by 1.5×. It is an uncommon disease that has been diagnosed with increasing frequency since the widespread appearance of coronary angiography. The published incidence varies from 1.5% to 5%, suggesting male dominance and a predilection for the right coronary artery. Although several causes have been described, atherosclerosis accounts for ≥50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture, and vasospasm, causing ischemia, heart failure, or arrhythmias. The natural history and prognosis remain unknown, as definitive data are scarce. Controversies persist regarding the use of medical management (antithrombotic therapy) or interventional/surgical procedures. Only some case reports or small case series are available about this condition. The Coronary Artery Aneurysm Registry (CAAR; http://www.ClinicalTrials.gov NCT02563626) is a multicenter international ambispective registry that aims to provide insights on anatomic, epidemiologic, and clinical aspects of this substantially unknown entity. In addition, the registry will assess management strategies (conservative, interventional, or surgical) and their short- and long-term results in a large cohort of patients. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov. Unique identifier: NCT02563626.

Anomalous origin of the right coronary artery from the pulmonary artery diagnosed as an incidental finding.

A 2-year-old boy was referred for evaluation of a systolic heart murmur. Two-dimensional Doppler echocardiogram showed an abnormal flow through the interventricular septum, directed upward and toward the posterior wall of the main pulmonary artery. Left coronary angiogram showed a normal distribution of the anterior descending and circumflex arteries. The right coronary artery (RCA) was fully filled through collaterals from the left coronary system, and arising from the main pulmonary artery. Successful surgical reimplantation of the RCA was undertaken. Although uncommon, it is important to recognize the anomalous origin of the RCA arising from the pulmonary artery since it can be associated with serious adverse cardiac events.

[TIMI risk score validation for patients with acute coronary syndrome without ST elevation]. / Validación del score de riesgo TIMI para pacientes con síndrome coronario agudo sin elevación del ST.

Non-ST elevation acute coronary syndromes (NSTE-ACS) are frequent cause of hospitalization, being responsible for 10-15% of infarcts or deaths per year. The study was designed to analyze 6 months follow-up of cardiovascular events as well as to validate the Thrombolysis in Myocardial Infarction (TIMI) risk score for patients hospitalized for NSTE-ACS. We retrospectively analyzed patients admitted with NSTE-ACS. Telephone follow-up were performed at 6 month. Combination of death, re-admission for acute coronary syndrome and revascularization were considered as end point. Two hundred and four patients were included for the analysis. There were 70.2% males, with a mean age of 64.5 +/- 11.8 years. After the initial evaluation, we diagnosed unstable angina in 34.6% of cases, MI in 38.9% of cases, and 26.4% of patients were categorized as "non coronary chest pain". Applying the TIMI risk score, 52 (25.5%) patients had low risk, 106 (52%) intermediated risk, and 46 (22.5%) high risk. The global mortality was 12.3%. We found a progressively and significant increase in the rate of combined events as the TIMI score increase (p < 0.001). We conclude that in our population, the intermediated and high TIMI risk score was well related to newer cardiovascular events at 6 month follow-up.

Validación del score de riesgo TIMI para pacientes con síndrome coronario agudo sin elevación del ST / TIMI risk score validation for patients with acute coronary syndrome without ST elevation

Los síndromes coronarios agudos sin elevación del segmento ST (SCA-SST) son causa frecuente de hospitalización, siendo responsables del 10 al 15% de infartos de miocardio (IM) o muertes al año. El objetivo fue evaluar eventos cardiovasculares a 6 meses de seguimiento y validar el score de riesgo TIMI (Thrombolysis in Myocardial Infarction) en nuestra población. Se analizaron retrospectivamente pacientes con diagnóstico de SCA-SST. Se realizó seguimiento telefónico a los 6 meses del ingreso. Los puntos finales evaluados fueron la combinación de muerte, internación por síndrome coronario agudo y necesidad de revascularización. Se incluyeron 204 pacientes. El 70.2% eran hombres, edad promedio de 64.5 ± 11.8 años. Luego de la evaluación inicial, se hizo diagnóstico de angina inestable en el 34.6%, IM en 38.9% y el 26.4% fueron catalogados como "dolor no coronario". Al aplicar el score de TIMI, 52 (25.5%) pacientes tenían riesgo bajo, 106 (52%) riesgo intermedio, y 46 (22.5%) riesgo alto. La mortalidad global fue 12.6%. Se encontró un incremento progresivo y significativo en la tasa de eventos combinados a medida que aumentaba el score de TIMI (p < 0.001). Concluimos que, en nuestra población, encontramos de gran utilidad al score de riesgo TIMI, ya que los pacientes con score intermedio y alto se correlacionaron con nuevos eventos cardiovasculares a 6 meses de seguimiento.

Non-ST elevation acute coronary syndromes (NSTE-ACS) are frequent cause of hospitalization, being responsible for 10-15% of infarcts or deaths per year. The study was designed to analyze 6 months follow-up of cardiovascular events as well as to validate the Thrombolysis in Myocardial Infarction (TIMI) risk score for patients hospitalized for NSTE-ACS. We retrospectively analyzed patients admitted with NSTE-ACS. Telephone follow-up were performed at 6 month. Combination of death, re-admission for acute coronary syndrome and revascularization were considered as end point. Two hundred and four patients were included for the analysis. There were 70.2% males, with a mean age of 64.5 ± 11.8 years. After the initial evaluation, we diagnosed unstable angina in 34.6% of cases, MI in 38.9% of cases, and 26.4% of patients were categorized as "non coronary chest pain". Applying the TIMI risk score, 52 (25.5%) patients had low risk, 106 (52%) intermediated risk, and 46 (22.5%) high risk. The global mortality was 12.3%. We found a progressively and significant increase in the rate of combined events as the TIMI score increase (p < 0.001). We conclude that in our population, the intermediated and high TIMI risk score was well related to newer cardiovascular events at 6 month follow-up.

[Clinical characteristics and tilt test of patients with vasovagal syncope suspicion]. / Características clínicas y Tilt test de pacientes con sospecha de síncope vasovagal.

BACKGROUND: Vasovagal syncope is the most common cause of syncope and is an amount medical, social and economic problem. MATERIAL AND METHODS: We study a population of patients with history of syncope of presumed vasovagal origin submitted to head-up tilt test (TT) with intention to describe and to compare symptoms, signs and trigger situations between positive and negative TT. Twenty four variables were investigated (chosen according to the clinical experience). RESULTS: One hundred thirteen patients were included. The age mean was 33,3 ± 19,4 years and 67.3% corresponded to women. 81 patients (71,7%) experienced syncope during test. The more frequent response was mixed subtype (58 %), followed by vasodepressor response (30,9%) and cardioinhibitory response (11,1%). There were not significant differences between both groups in symptoms, signs and trigger situations. In patients with negative TT was more frequent syncopes triggered by extreme exercise (p = 0,012). CONCLUSION: In patients with vasovagal syncope suspicion, a clinic history does not predict TT results.

[Endocarditis of pacemaker or implantable cardioverter-defibrillator leads]. / Endocarditis relacionada a cables de marcapasos o cardiodesfibriladores implantables.

BACKGROUND: Infective endocarditis includes the endovascular devices infection. The main objective was to evaluate the clinical characteristics and evolution of the endocarditis related to electronics devices. CASE REPORTS: Between 2002 - 2007 periods were identified 7 patients, age average of 56.5 years. The clinical presentation was fever of unknown origin in 85.7%, with a mean of 28 days of evolution. The microbiology isolated was coagulase-negative staphylococci in 6 patients and staphylococcus aureus in 1 patient. The treatment was complete system extraction and antibiotic therapy, except in 1 case that only received antibiotics. There were 2 deaths (28,5%) during in hospital follow-up. CONCLUSION: The endocarditis related to devices is a disease with high mortality. Early diagnosis and system extraction are very important for the treatment and prognosis.

Comparación de valores de NT pro BNP en pacientes con fibrilación auricular con y sin trombos en orejuela deaurícula izquierda: experiencia inicial / NT pro BNP levels comparation between patients with and withoutleft atrial appendage thrombi: initial expereince

El péptido natriuretico cerebral (BNP) ha sido propuesto como indicador de disfunción de la orejuela de la aurículaizquierda (OAI) en fibrilación auricular (FA) no valvular; siendo esta un factor protrombotico local. El objetivo del trabajo fue demostrar una mayor concentración de la fracción n-terminal del BNP (NT pro BNP) en aquellos pacientes con FA y trombos en la OAI. Se seleccionaron 11 pacientes, 3 pacientes en el grupo 1 (con trombo en OAI) y 8 pacientes en el grupo2 (sin trombo en OAI). La media de NT pro BNP fue de 832 pg/ml vs 694 pg/ml, grupo 1 y 2 respectivamente (p= 0,30). Concluimos entonces, que si bien el valor de BNP marcó una tendencia a favor, no tuvo relación con la presencia de trombo en OAI, pero necesitamos un mayor número de pacientes para rechazar esta hipótesis

Endocarditis relacionada a cables de marcapasos o cardiodesfibriladores implantables / Endocarditis of pacemaker or implantable cardioverter-defibrillator leads

Antecedentes: Dentro del síndrome de endocarditis infecciosa, se incluyen la infección de dispositivos endovasculares. el objetivo de la presentación fue avaluar las características clínicas y la evolución de la endocarditis relacionada a dispositivos electrónicos endovasculares. Casos clínicos: entre 2002 - 2007 fueron identificados 7 pacientes con edad promedio de 56,5 años. La presentación clínica fue en el 85,7% fiebre de origen desconocido, con un promedio de 28 días de evolución del cuadro. Los germenes aislados fueron estafilococo coagulasa negativo en 6 pacientes y estafilococo aureus en 1 paciente. El tratamiento se baso en la extracción del sistema y terapia antibiótica, salvo 1 caso que solo recibió tratamiento antibiótico. Hubo 2 (28,5%) muertes intrahospitalarias durante el seguimiento. Conclusión: La endocarditis relacionada a dispositivos es una entidad con elevada mortalidad. el diagnóstico temprano y la extracción del sistema son de vital importancia para el tratamiento y pronóstico.

BACKGROUND: Infective endocarditis includes the endovascular devices infection. The main objective was to evaluate the clinical characteristics and evolution of the endocarditis related to electronics devices. CASE REPORTS: Between 2002 - 2007 periods were identified 7 patients, age average of 56.5 years. The clinical presentation was fever of unknown origin in 85.7%, with a mean of 28 days of evolution. The microbiology isolated was coagulase-negative staphylococci in 6 patients and staphylococcus aureus in 1 patient. The treatment was complete system extraction and antibiotic therapy, except in 1 case that only received antibiotics. There were 2 deaths (28,5%) during in hospital follow-up. CONCLUSION: The endocarditis related to devices is a disease with high mortality. Early diagnosis and system extraction are very important for the treatment and prognosis.

[Ischemic hepatitis]. / Hepatitis isquémica.

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term "hepatitis" was proposed because of a raise in hepatic enzymes similar with infectious disease, and "ischemic" because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presented complaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracic echocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative.

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de “hepatitis” fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e “isquémica” por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term “hepatitis” was proposed because of a raise in hepaticenzymes similar with infectious disease, and “ischemic” because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de ¶hepatitis÷ fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e ¶isquémica÷ por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos (AU)

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term ¶hepatitis÷ was proposed because of a raise in hepaticenzymes similar with infectious disease, and ¶ischemic÷ because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative (AU)

Hepatitis isquemica / Ischemic hepatitis

La hepatitis isquémica es una complicación sumamente infrecuente de cirugía cardiovascular. Las biopsias muestran necrosis centrolobulillar. El término de ¶hepatitis÷ fue propuesto debido al aumento de transaminasas similar a aquellas de origen infeccioso, e ¶isquémica÷ por falla en la perfusión hepática. Posteriormente se definió el término de hepatitis isquémica como cuadro de elevación aguda y reversible(dentro de las 72 horas) de transaminasas de hasta 20 veces el valor normal, asociado a trastornos en la perfusión hepática, luego de haber excluido otras causas de hepatitis aguda o daño hepatocelular. Se describe elcaso de un paciente de 53 años que consulta por dolor epigástrico de 12 h de evolución sin fiebre, náuseas nivómitos, resistente a la medicación. Tenía antecedentes inmediatos de reemplazo de válvula aórtica, y estabaanticoagulado. Evolucionó con shock y fallo multiorgánico. El examen evidenció marcada ictericia y signos detaponamiento pericárdico, asociado a un aumento considerable de enzimas hepáticas. Un ecocardiograma informósignos de taponamiento cardíaco y ausencia de disección aórtica. Se decidió pericardiocentesis, extrayéndose 970 cc. de líquido sanguinolento, y hemodiálisis, con notable mejoría de su estado hemodinámico. Los valores enzimáticos disminuyeron. Los marcadores virales fueron negativos (AU)

Ischemic hepatitis is an uncommon cardiovascular surgery complication. Hepatic biopsies show centrolobulillar necrosis. The term ¶hepatitis÷ was proposed because of a raise in hepaticenzymes similar with infectious disease, and ¶ischemic÷ because of failure in hepatic perfusion. Ischemic hepatitis was then defined as an acute and reversible elevation of hepatic enzymes (within 72 h), associated with disturbance in hepatic perfusion after excluding other causes of acute hepatitis. A 53 year-old male presentedcomplaining of a 12 h epigastric pain, without nausea or vomiting, resistant to medication. He underwent an aortic valve replacement and was under anticoagulation. He suddenly developed shock and multiorgan failure. Jaundice and cardiac tamponade signs were present, associated with elevated hepatic enzymes. A transthoracicechocardiography accounted for cardiac tamponade signs. A pericardiocentesis was performed, removing 970 cc of hemorrhagic fluid, and hemodialysis, with improvement of his hemodynamic status. Hepatic enzymes improved. Viral markers were negative (AU)