[Intracoronary stents in small vessels: short- and long-term clinical results]. / Stents intracoronarios en vasos pequeños: resultados clínicos a corto y largo plazo.

OBJECTIVE: To assess the clinical outcome of coronary stenting in small vessels (< 3 mm), using high pressure balloon inflation and antithrombotic therapy. PATIENTS AND METHODS: Vessel size was evaluated as < or >= 3 mm at the time of procedure and measured at a level of maximum diameter. We studied 234 consecutive patients with placement of 300 stents in 279 lesions, comprising 84 stents implanted in 79 lesions located at small vessels (< 3 mm). The standard technique included high pressure balloon inflation (15.8 +/- 2.2 atm) and post-stenting therapy with ticlopidine and aspirin for one month. Mean clinical follow-up was 17.6 +/- 10 months. RESULTS: Procedural success without in-hospital major events was similar between small and large vessels (93.7 in vessels of < 3 mm vs 93.5% in vessels of >= 3 mm; p = NS). Three small vessels presented subacute stent thrombosis, whereas no thrombotic occlusion occurred in large vessels (3.8 vs 0%; p = 0.006). At two years, small vessels had a lower target lesion revascularization free survival (73.6 vs 90.3%; p < 0.001). After adjustment for variables previously described as predictors of stent restenosis, in multivariate analysis, a small vessel of < 3 mm was an independent predictor of target lesion revascularization (p = 0.001). Although patients with stenting in small vessels did not differ significantly in terms of any cause death (4.6 vs 3.8%; p = 0.7) nor acute myocardial infarction (2.9 vs 1.1%; p = 0.3), event-free survival was significantly lower after two years (69.1 vs 86.6%; p < 0.001). CONCLUSIONS: As compared to large vessels, coronary stenting in small vessels was performed with similar rates of initial success, however they had a significantly worse clinical long-term outcome in terms of subacute stent thrombosis and target lesion revascularization at follow-up.

[The effectiveness of stents in restinotic lesions and coronary grafts]. / Eficacia del stent en las lesiones reestenóticas e injertos coronarios.

Regarding restenotic lesions, the data suggest that stent implantation decrease the number of cardiac events including the restenosis rate. The higher number of acute cardiac events are related to stent thrombosis, and they are markedly reduced by the new techniques of antiagregation and implantation. The restenosis rate post-stent implantation does not bear relation to the number of previous dilations as it does with conventional angioplasty. Regarding vein grafts, the implantation of different types of stents has a high percentage of success and low rate of acute complications. The longterm survival of these patients is related more to the progression of the coronary arteriosclerosis and tend to worsen with time. Although the data on restenosis are better than with conventional angioplasty, we need to wait for the definitive results after the final conclusions of the randomized trial SAVED.

[Usefulness of transesophageal echocardiography in the diagnosis of coronary anomalies]. / Utilidad de la ecocardiografía transesofágica en el diagnóstico de anomalías coronarias.

BACKGROUND: Although rare, anomalous coronary arteries are associated with myocardial ischemia and sudden death. Identification is made by angiography but its true course is difficult to determine even with this invasive procedure. OBJECTIVES: The purpose of this study is to determine the role of transesophageal echocardiography (TEE), Doppler and color flow Doppler, in identifying the origin and course of anomalous coronary arteries. MATERIAL AND METHODS: Six patients with angiographically confirmed anomalous coronary arteries were studied by TEE, Doppler and color flow Doppler. RESULTS: The abnormal origin was confirmed in all six patients. In three, the left main originated from the right sinus of Valsalva. In one the right coronary artery from the left sinus of Valsalva. One was a single right coronary artery from the right sinus of Valsalva, and one, had a fistula between the coronary artery and the right ventricle. In four, the TEE was able to demonstrate clearly the course in relation to the great vessels, two were interarterial and one posterior. Color flow Doppler was obtained in four patients. In one patient, there was increase in diastolic flow velocity due to proximal coronary obstruction. One had increase of the systolic flow velocity. CONCLUSIONS: TEE is useful test for diagnosing the origin of anomalous coronary arteries and confirming its course in relation to the great vessels. Doppler flow Doppler is useful in localization the vessel.

[Complications at the first month following various types of intracoronary stents, implanted with high pressure without intracoronary ultrasonography or anticoagulation]. / Complicaciones en el primer mes de varios tipos de stents intracoronarios, implantados a altas presiones sin ayuda de ultrasonidos intracoronarios ni anticoagulación.

BACKGROUND: Coronary stents have proved their efficacy in bail-out situations and restenosis. Nevertheless, the high incidence of subacute thrombosis and vascular and bleeding complications limits its use. OBJECTIVES: To evaluate the clinical complications during the first month of three different types of stents, implanted with high pressure, without ultrasound guidance or anticoagulation. PATIENTS AND METHODS: All stents were implanted in arteries of 3 mm or more. After implantation, all stents were dilated between 15-17 atmospheres, aiming to a residual stenosis lower than 10%. After implantation, all patients received aspirin indefinitely and ticlopidine 250 mg twice daily for one month. The initial success, the ischemic complications (death, myocardial infarction and emergency surgery), acute and subacute thrombosis and vascular and hemorrhagic complications were evaluated. The evaluation was done following the procedure, prior to discharge from the hospital and at 1 month follow-up. RESULTS: In 49 patients, 51 stents were implanted. 70% had unstable angina. In one case the stent was implanted after primary PTCA. In 17.6%, the stent was implanted in a bail-out situation. Of the 51 stents, 32 were Palmaz-Schatz, 12 Wiktor and 7 Gianturco-Roubin. The initial success was 100%. There were no deaths, AMI, nor emergency surgeries in the first month. There was no case of acute or subacute thrombosis. There were 2 minor complications; one vascular: a pseudoaneurysm, and another hemorrhagic: an inguinal hematoma. Neither case needed surgery nor blood transfusion. All patients were discharged within 48 hours. CONCLUSION: Implantation of stents with high pressures, in spite of not using guidance ultrasound nor anticoagulation, is safe and effective, with a clear decrease in vascular complications, and without an increase in the incidence of acute or subacute thrombosis.

[The anomalous origin of the left common coronary trunk in the right sinus of Valsalva with an interarterial path. Apropos a case]. / Origen anómalo del tronco coronario común izquierdo en el seno de Valsalva derecho con trayecto interarterial. A propósito de un caso.

We present the case of an old patient with coronary artery disease and two previous myocardial infarctions, admitted to the hospital by syncopal episodes, in which the coronariographic study showed the ectopic origin of the left main coronary artery in the right sinus of Valsalva with anomalous course between the aortic and pulmonary arteries. In this case the initial coronariographic diagnosis and the therapeutical attitude (initially aggressive only in cases of interarterial course) was confirmed by mean of transesophageal echocardiography, showing a better topographical definition of the ectopic vessel aberrant course, although due to the high degree of left ventricular disfunction and the diffuse disease of distal vessels in this patient, CABG surgery was avoided. The angiographic feature is described and the transesophageal approach is remarked as a complementary diagnostic tool in the correct definition of the anomalous course.

[The spectral analysis of the P wave in patients with paroxysmal atrial fibrillation]. / Análisis espectral de la onda P en pacientes con fibrilación auricular paroxística.

INTRODUCTION AND OBJECTIVE: The aim of this study is to establish if patients with paroxysmal atrial fibrillation have an abnormal spectrum of the P wave. PATIENTS AND METHODS: Thirty-five patients with previous documented atrial fibrillation were compared with a control group of 29 patients. A signal-averaged ECG was performed using an ART-1200-EPX system, and a segment covering the last 75 ms of the P wave and the next 25 mg was analyzed in each of three orthogonal leads (X, Y, Z) and in a combined one (C). The area under the spectral curve between 20 and 50 Hz was divided by the area between 0 and 20 Hz (x 100 = AR50). RESULTS: Patients with paroxysmal atrial fibrillation had greater AR50 on leads Y (78.3 +/- 42.9 vs 54.4 +/- 14.8; p < 0.01) and C (82.2 +/- 52.1 vs 58.4 +/- 14.6, p < 0.05) when compared with the control group. In the subset of patients without structural heart disease AR50 in lead X was greater. The criterion "AR50 > 55 in lead Y" identified paroxysmal atrial fibrillation with a sensitivity of 77.1% and a specificity of 85%. CONCLUSIONS: This method may be useful to detect patients at risk for paroxysmal atrial fibrillation.

[Mitral valve insufficiency in acute myocardial infarction. Assessment with pulsed and coded Doppler color]. / Insuficiencia mitral en el infarto agudo del miocardio. Valoración con Doppler pulsado y codificado en color.

We studied 108 patients who sustained an acute myocardial infarction (AMI) by means of echocardiography, pulsed doppler (PD) and Doppler color flow imaging (CD). We evaluate the presence of mitral regurgitation (MR) and it relationship to the site of the AMI and also to the ventricular function. The incidence of MR was 50.92%, (55/108), it was detected in higher percentage when the AMI was inferior (61.8%) than when anterior (39.6%). The correlation with the ejection fraction (EF) was only significative when the AMI was anterior. The incidence of MR was 57.1% when the EF was below 25%. CD had better diagnostic capabilities independently of the site of the AMI, (48% vs 32.1% when the AMI was anterior and 76.1% vs 52.6% when it was inferior).

[Study of the influence of arterial pressure response to exertion on cardiac hypertrophy in patients with mild or moderate hypertension]. / Estudio de la influencia de la respuesta de la presión arterial al esfuerzo sobre la hipertrofia cardíaca en hipertensos ligeros y moderados.

In order to study the relationship between tensional response of an hypertensive patient to exercise and its cardiac repercussions, we have studied 42 essential hypertensive patients using echocardiography type M and 2D and exercise test. Patients were divided into two groups according to whether they had (GI) or not (GII) left ventricular hypertrophy. LVH was defined calculating left ventricular mass (LVM) or mean wall thickness (MWT). We have found significant correlations between tensional response and LVH, using only MWT as the index of LVH. This correlation was significant not only with maximum systolic arterial pressure but also with systolic arterial pressure in all intermediate charge stages. Evolution time of arterial hypertension significantly correlated with the degree of LVH according to MWT and less significantly with LVM. We conclude that the correlation between tensional response to exercise and cardiac hypertrophy is always higher when considering MWT as the index of LVH since the calculating the mass some other parameters are also present which hinder its significance and that correlation is established not only in the maximum exercise level.

[Study of blood pressure response to exertion in essential hypertension. Its modification with anti-hypertensive treatment]. / Estudio de la respuesta tensional al esfuerzo en hipertensos esenciales. Su modificación con el tratamiento antihipertensivo.

We have studied the effect of atenolol, xipamide, and verapamil in the control of effort tensional response in 54 patients suffering essential hypertension. A first effort test without treatment and a second after a one month treatment randomly assigned were performed in all patients, evaluating the tensional response at 30, 60 and 80 Watts of charge, maximum peak, and after five minutes in recovery. Atenolol significantly reduced (p less than 0.05) systolic arterial pressure and diastolic arterial pressure in every intermediate effort stage, maximum peak and post effort recovery, xipamide, also significantly reduced (p less than 0.05) the systolic hypertensive response at all different levels, however, the diastolic one did not reach any statistic significance. Verapamil at used doses did not modify neither systolic nor diastolic hypertensive response. The beneficial effect of beta-blockers is confirmed although we could not confirm the effect pointed out by other authors regarding calcium antagonists. Tensional control using xipamide was striking although there is some evidence to think that it can have a more important effect in the control than thiazide diuretics or amiloride.

[Heart hydatidosis diagnoses with bidimensional echocardiography]. / Hidatidosis cardíaca diagnosticada por ecocardiografía bidimensional.

A case of calcificated intramyocardiac hydatid cyst is presented. The initial diagnosis was coronary artery disease and the onset was chest pain and typical abnormalities of the electrocardiogram. The diagnosis of hydatid disease was suspected from chest roentgenogram and confirmed by two-dimensional echocardiography and left ventriculography. Coronary arteriography was normal and surgical treatment successfully carried out.

[Doppler echocardiography in cor triatriatum: apropos of 2 cases]. / Ecocardiografía Doppler en el cor triatriatum: a propósito de 2 casos.

In this communication we present a Doppler-echocardiographic investigation on two cases of cor triatriatum. The echocardiographic features and the pulsed Doppler findings, which have not been published previously, are also discussed. When the Doppler sample volume is positioned in the distal camera of the left atrium from apical projections, a positive systolic flow is obtained. This finding has not been described, to our knowledge, in the cor triatriatum nor in any other cardiac abnormality. It is our thought that flow studies in the left atrium in cases of cor triatriatum can be a useful aid to the echocardiographic diagnosis of the anomaly. Doppler studies are also helpful in the differential diagnosis with other intracavitary images, and it is probably also useful in the assessment of the degree of obstruction at the membrane level.

[Dynamic intracavitary echoes from non-slow flow in a patient with a mitral prosthesis]. / Ecos dinámicos intracavitarios por flujo no lento en un paciente con prótesis mitral.

The infrequent finding of visualization of circulating blood by two-dimensional echocardiography in the left ventricle in a patient with a mitral prosthetic valve is reported. In contrast to most of the reports on dynamic intracavitary echoes, no correlation with blood stasis or diminished flow velocity is found, being normal in this pulsed Doppler study.