Terapia de revascularización percutánea en pacientes portadores de estenosis crítica carotídea-coronaria: resultados en un hospital y a largo plazo / Percutaneous revascularization therapy in patients of critical carotid-coronary stenosis: results in hospital and long term

Objetivo: Analizar la morbimortalidad a 30 días y 6 meses en pacientes sometidos a una intervención percutánea (IP) por estenosis critíca carotídea (EAC)-coronaria (EACo) en un centro hospitalario de alto volumen, experto en el tratamiento de la enfermedad multivascular. Antecedentes: El tratamiento óptimo de los pacientes con EAC y EACo concomitante sigue siendo controvertido. Ha sido reportada una variedad de estrategias terapéuticas, incluyendo a la cirugía de revascularización coronaria (BACo), sola o en combinación con la revascularización percutánea o quirúrgica de la arteria carótida. Material y métodos: Entre enero de 1998 y junio de 2013 fueron tratados 118 (149 lesiones) pacientes consecutivos con EAC (estenosis carotídea sintomática en el 37.6%) y EACo en forma estadiada o simultánea a IP carotídeo-coronario con stent. El objetivo primario (PP) fue evaluar la incidencia de los eventos cardiacos y cerebro-vasculares mayores (ECVM) (muerte, infarto al miocardio y accidente vascular cerebral mayor) en los 30 días posteriores, tanto al primero como segundo procedimiento. Con un EuroSCORE (ES) promedio de 2.75 ± 1.5. Resultados: A 30 días, la incidencia de PP fue de 4.02%; la muerte global infarto agudo al miocardio (IAM) y accidente vascular cerebral mayor (AVCM) ocurrieron en el 2.01, 1.34 y 0.67% respectivamente; no observamos diferencia en AVC mayor y muerte en el grupo Sx versus Asx, 2.14% versus 2.14%, p = 0.809; ambos grupos, sin embargo, en el infarto fue mayor en Asx versus Sx 4.3% versus 0%, p = 0.053. Se hizo un seguimiento a seis meses de 140 lesiones tratadas; cuatro pacientes se sometieron a revascularización coronaria, uno falleció, tres de ellos presentaron IAM y muerte cardiovascular, 0% de AVC ipsilaterales; 1.4% presentó reestenosis in stent carotídeo tratándose con angioplastia balón (ATP). Conclusiones: En los pacientes con EAC y EACo concomitante, un tratamiento percutáneo combinado se compara muy favorablemente con las experiencias quirúrgicas o híbridos con evidente menor ECVM. Tal estrategia puede ser especialmente más adecuada a pacientes complejos con alto riesgo quirúrgico.

Objectives: To analyze the morbidity and mortality at 30 days and 6 months in patients taken to a Percutaneous Intervention (PI) for critical Carotid and coronary stenosis in a center of high volume expert in the treatment of multivessel disease. Background: The optimal treatment of patients with Carotid and Coronary disease concomitant remains controversial. A variety of therapeutic strategies, including coronary artery bypass surgery (CABG), alone or in combination with percutaneous or surgical revascularization of the carotid artery have been reported. Material and methods: Between January 1998 and June 2013, 118 patients with (149 lesions) carriers of Coronary and Carotid disease (symptomatic carotid stenosis in 37.6%) were treated as staged or simultaneous PI Carotid-Coronary stenting. The primary endpoint (EP) to assess the incidence of major cerebrovascular and cardiac events (MACE) (death, myocardial infarction, cerebral vascular accident major) within 30 days after the first and second proceedings, with EuroSCORE (ES) 2.75 ± 1.5 avg. Results: The incidence of EP was 4.02%, global death, acute myocardial infarction (AMI) and cerebral vascular accident major (CVAM) occurred in 2.01, 1.34 and 0.67% respectively. In group Asx versus Sx we not observed a greater difference in the CVAM and death 2.14% versus 2.14%, p = 0.809 both groups, however in AMI was higher in Asx versus Sx group 4.3% versus 0%, p = 0.053. At 6 month follow up 4 patients underwent CABG one dies, 3 patients more presented AMI and death, 0% ipsilateral CVA, 1.4% had carotid stent restenosis with being treated PTA. Conclusions: In patients with carotid and coronary stenosis concomitant, combined percutaneous treatment compares very favorably to previous surgical or hybrid experiences less obvious MACE. This strategy may be particularly suited to more complex patients with high surgical risk.

Cierre percutáneo primario del defecto del tabique interventricular postinfarto con el dispositivo de Amplatzer: resultados inmediatos y seguimiento a largo plazo / Primary percutaneous closure of postinfarction septal defect with Amplatzer device: immediate results and long-term follow-up

Introducción: La reparación quirúrgica inmediata de una comunicación interventricular que complica el infarto agudo del miocardio (CIV post-IAM) se asocia con la alta mortalidad. El cierre con dispositivo percutáneo parece ser seguro y efectivo en pacientes con CIV post-IAM; reportamos los resultados inmediatos y a largo plazo en la utilización del dispositivo Amplatzer en el cierre primario de una CIV post-IAM. Material y métodos: De junio del 2006 a enero del 2014, 17 pacientes portadores de una CIV post-IAM se sometieron a un cierre percutáneo con Amplatzer a una edad promedio de 66.8 ± 5.5, 82.4% en shock cardiogénico (ShC), el 35.3% recibieron tratamiento trombolítico (TT) en ventana, el tiempo promedio del diagnóstico de CIV al cierre percutáneo (IP) fue de 8.7 ± 5.8 días. Resultados: Con un seguimiento actual de 13.25 ± 12.6 meses, el éxito del procedimiento fue del 100%, el shunt (QP:QS) se redujo de 2.9 ± 0.95 a 1.5 ± 0.40 L/min p = 0.0001, 12 pacientes (70.6%) se sometieron a una Angioplastía Coronaria Transluminal Percutánea (ACTP) del vaso culpable posterior al cierre de la CIV. La mortalidad a 30 días fue de 52.9%, siendo más alta en el paciente con ShC versus no-ShC 64.3 versus 0% p = 0.043 OR 2.8 (IC 95% 1.38-5.6). Conclusión: El cierre primario de CIV post-IAM es una técnica muy promisoria que puede ser realizada con una alta tasa de éxito y mínimas complicaciones y puede ser tomado como una alternativa a la cirugía. Sin embargo, a pesar de ser una técnica menos invasiva, la mortalidad permanece alta y muy evidente en el paciente en ShC.

Introduction: The immediate surgical repair of a ventricular septal defect complicating acute myocardial infarction (VSD post-AMI) is associated with high mortality. The percutaneous closure device is safe and effective in patients with post-infarction VSD; we report the immediate and long term results in the use of the Amplatzer device in the primary closure of post infarction VSD. Material and methods: From June 2006 to January 2014, 17 patients carriers of post-infarction VSD underwent percutaneous Amplatzer closure with a mean age 66.8 ± 5.5, 82.4% in cardiogenic shock (CS), 35.3% were thrombolyzed (TT) in window, the average time to percutaneous closure of VSD 8.7 ± 5.8 days. Results: With a current monitoring of 13.25 ± 12.6 months procedural success were in 100% shunt (QP:QS) was reduced from 2.9 to 1.5 ± 0.40 ± 0.95 L/min p = 0.0001, 12 patients (70.6%) undergoing PTCA the culprit vessel post-closure of the VSD. Global mortality at 30 days was 52.9%, being higher in patients with CS versus 64.3 versus 0% no-CS p = 0.043 OR 2.8 (CI 95% 1.38-5.6). Conclusion: The primary closure of postinfarction VSD is a very promising technique that can be performed with a high success rate and minimal complications and may be taken as an alternative to surgery. However despite being a less invasive technique remains high mortality very evident in patients in CS.

[Heart transplant in Monterrey, Nuevo León]. / Trasplante cardiaco en Monterrey, Nuevo León.

Heart failure constantly increases its incidence and prevalence in our society, it was imperative to start a heart transplant program to improve the survival rates of patients with end stages of the disease. Legal issues made impossible to transplant patients out of Mexico City until recent years. Even with an acute hemodynamic and clinic improvement after the transplant, these patients frequently develop complications such as graft rejection or opportunistic infections due to the immunosuppressive schemes increasing the morbidity and mortality of the procedure. In the present article we report the experience acquired with 65 heart transplant patients from 4 transplant programs in Monterrey, Nuevo Leon, one of them from the socialized system and the other three from private hospitals. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even that we have faced obstacles like a newly started donation culture in our population and limited resources, our patient's survival rate push us to continue working with these very ill population.

Experimental Right Atrial Ischemia and Its Response to Stimulation with Dobutamine.

In order to analyze the repercussion of experimental isolated selected right atrial ischemia on the hemodynamics of both ventricles, we investigated the response of atrial myocardium with administration of dobutamine and evaluated the utility of transesophageal echocardiography (TEE) with Doppler in the examination of alterations produced by atrial ischemia. Ten dogs were studied with normal, diminished, and increased cardiac output with ligation of the visible atrial branches of the right coronary artery. Right atrial wall movement and peak A wave velocity of tricuspid flow registered by TEE decreased (P < 0.05). The amplitude of the right atrial A wave decreased in hemodynamic recordings (P < 0.05). No significant modifications occurred in right ventricular wall movement nor in pressures registered in right or left ventricles or cardiac output. Seventy-five minutes after atrial ischemia was induced dobutamine was administered. In dogs with incomplete ligations of atrial circulation, right atrial wall movement improved (P < 0.001), and the amplitude of the peak A wave velocity of tricuspid flow increased. In dogs with complete coronary ligation, administration of the medication produced no improvement of these variables. The findings indicate that it is possible to produce selective right atrial ischemia manifested by diminished wall movement, a diminished atrial component of tricuspid flow in TEE, and decreased amplitude of the A wave in atrial pressure recordings. The localized hemodynamic changes produced by right atrial ischemia are not related to variations in venous return when right ventricular function is normal. Apparently isolated right atrial damage from ischemia does not affect ventricular function if these remain healthy. The recuperation of atrial contractility can be demonstrated with dobutamine. Transesophageal echocardiography is a very useful technique for studying right atrial ischemia and infarction.