[Case report: ablation of atrial fibrillation in patient with an interatrial septal oclussion device]. / Ablación de fibrilación auricular en paciente con dispositivo de oclusión septal interatrial. Reporte de un caso.

Interatrial septal occlusion devices hinder the transseptal approach for atrial fibrillation ablation, making it necessary to have imaging methods that safely guide transseptal puncture, such as intracardiac echocardiography (ICE). We describe the case of a 49-year-old patient with symptomatic paroxysmal atrial fibrillation, refractory to antiarrhythmic drugs, wearing an interatrial septal occlusion device, with a previous unsuccessful ablation attempt. Atrial fibrillation ablation was performed using the Carto V7 3D mapping system, the transseptal puncture was guided by ICE, and the procedure was successful. This case report highlights the importance of multimodality imaging to achieve successful and effective transseptal puncture for atrial fibrillation ablation in patients with interatrial septal occlusion devices.

[Quality of life in patients with idiopathic ventricular arrhythmias treated at the Instituto Nacional Cardiovascular - INCOR]. / Calidad de vida en pacientes con arritmias ventriculares idiopáticas tratados en el Instituto Nacional Cardiovascular - INCOR.

Objective: To describe the quality of life in patients with idiopathic ventricular arrhythmias treated at the Instituto Nacional Cardiovascular INCOR in Lima -Peru. Materials and methods: . Analytical and cross-sectional study of patients with idiopathic ventricular arrhythmias treated by 3D ablation or antiarrhythmic therapy between July 2017 and December 2019 to whom the SF-36 health questionnaire was applied to assess quality of life related to health. Results: Fifty-two patients with idiopathic ventricular arrhythmias were included (34 underwent 3D ablation, and 18 underwent antiarrhythmic therapy only). The percentage of recurrence (14.7% vs. 50%, p=0.01) and adverse effects (0% vs. 22.2%, p=0.011) were lower in the 3D ablation group compared to the antiarrhythmic group. The mean standardized scores obtained from the Spanish version of the Health Survey SF-36v2, applied to the 3D ablation and antiarrhythmic groups were 85.1 vs 68.4 (p<0.001), respectively. Were found statistically significant differences in 6 of the eight components that evaluate health-related quality of life: physical function (96.0 vs. 76.0, p<0.001), physical role (93.4 vs. 61.1, p<0.001), general health (74.5 vs. 47.4, p<0.001), vitality (69.9 vs 54.7, p=0.008), emotional role (92.2 vs. 77.8, p=0.006) and mental health (73.8 vs. 60, p<0.001). Conclusions: Patients with idiopathic ventricular arrhythmias who underwent 3D ablation have a higher mean standardized score for health-related quality of life.

[Cardiac arrhythmias and amyloidosis]. / Las arritmias en la amiloidosis cardiaca.

Cardiac amyloidosis (CA) is a form of cardiomyopathy characterized by the extracellular deposit of protein fibers in the myocardium, leading to the development of heart failure, arrhythmias, and electrical conduction system alterations. It is known that most cardiomyopathies have a close relationship with heart rhythm abnormalities, however, CA is specially related to different kinds of arrhythmias even in pre-diagnosis stages. Arrhythmias like atrial fibrillation are present in up to 70% of patients with CA associated with a high risk of cardioembolic complications independent of the risk stratification. Ventricular arrhythmias are frequent, but the use of implantable cardioverter defibrillator has not been demonstrated to improve survival. The Atrial-Ventricular node disease is also common, and is frequently associated with the implantation of a pacemaker, even in asymptomatic patients. In this review, we clarify the recommendations of the most current guidelines, summarize historical and contemporaneous data and describe evidence-based strategies for the management of arrhythmias and their complications in CA.

[Clinical profile and therapeutic strategies in patients with arrhythmogenic cardiomyopathy treated in a national reference institute]. / Perfil clínico y estrategias terapéuticas en pacientes con miocardiopatía arritmogénica tratados en un instituto de referencia nacional.

Objective: To determine the epidemiological, clinical, electrocardiographic, imaging characteristics and main therapeutic strategies performed in patients with arrhythmogenic cardiomyopathy treated in a national reference cardiovascular institute. Materials and methods: Observational, descriptive and retrospective study that attempts to identify the clinical characteristics, complementary tests and therapeutic strategies performed in patients with arrhythmogenic cardiomyopathy treated at the Instituto Nacional Cardiovascular - INCOR EsSalud in Lima, Peru. Results: Thirteen patients were found with arrhythmogenic cardiomyopathy. The median age at which the diagnosis was made was 38.2 years and 69.3% were male. The most frequent clinical manifestations were tachycardic palpitations (92.3%), presyncope (84.6%) and heart failure (69.2%). 23% of the patients suffered a cardiac arrest. All the patients presented at least one episode of ventricular tachycardia, 92.3% with complete left bundle branch block morphology and upper axis. 76.9% received an implantable cardioverter defibrillator (ICD), 15.3% underwent ablation and 15.3% received a heart transplant. 84.6% of the patients live to this day. Conclusions: Arrhythmogenic cardiomyopathy predominantly affected the young and male population. All the patients had a potentially fatal ventricular arrhythmia. Biventricular disease by echocardiography and cardiac magnetic resonance occurred in 69.2% and 100% of the cases, respectively. The therapeutic strategies used were antiarrhythmic medical treatment, placement of an ICD as secondary prevention, ablation, and heart transplantation. To date, 84.6% of patients survive.

[Ablation of cardiac arrhythmias using a three-dimensional electro-anatomical mapping system in the Instituto Nacional Cardiovascular - INCOR]. / Ablación de arritmias cardiacas empleando un sistema de mapeo electroanatómico tridimensional en el Instituto Nacional Cardiovascular - INCOR.

Objective: To describe the initial experience in ablation of cardiac arrhythmias using 3D mapping at the Instituto Nacional Cardiovascular INCOR (Lima, Peru). Methods: A retrospective descriptive study was carried out. During February 2020, data was collected from the medical records of all patients in whom ablation was performed using 3D mapping from July 2017 to December 2019. This procedure was performed in patients with symptomatic arrhythmia refractory to antiarrhythmic therapy. Results: Data were collected from 123 patients (median age: 46 years, 64.2% male), who had a median time of illness of 6 years. Among the arrhythmias treated, 19% had atrial fibrillation, 17.5% atrial tachycardia, 17.5% idiopathic ventricular arrhythmias, 16.6% Wolf Parkinson White syndrome / Atrioventricular reentrant tachycardia, 11.1% ventricular arrhythmias of the His-Purkinje conduction system, 9.5% scar related ventricular tachycardia associated, 6.4% atrial flutter and 2.4% intranodal tachycardia. The median fluoroscopy time was 26 minutes. Ablation was acutely successful in 95.9% of cases, acute complications were observed in 4.8%, and recurrence-free survival during the first year of follow-up was 74%. Conclusions: Our experience in ablation of cardiac arrhythmias using 3D mapping had a high acute success rate, low frequency of complications, and one-year recurrence-free survival of 74 %.

[Arrhythmias and Sudden Death Risk in Hypertrophic Cardiomyopathy]. / Arritmias y Riesgo de Muerte Súbita en Cardiomiopatía Hipertrófica.

The risk of sudden death in hypertrophic cardiomyopathy is related to the presence of ventricular arrhythmias in most cases. Finding the best schemes to assess the probability of arrhythmic complications will remain a challenge for modern Cardiology. Meanwhile, the multifactorial approach is the best strategy to avoid the unnecessary implantation of devices such as the implantable cardioverter defibrillator. Although the electrocardiogram remains an excellent diagnostic tool, even before echocardiographic expression, it does not have a clear role as a risk factor. However, the identification of associated arrhythmias such as preexcitation or long QT and variants of presentation as apical hypertrophic cardiomyopathy, allows identifying patients with high probability of sudden death. During the last few years, cardiac resonance and quantification of intramyocardial fibrosis (the basic mechanism of ventricular arrhythmias) have gained an important role in the evaluation of these patients.In particular, pediatric patients must have an individualized approach due to the poor prognosis at early ages and the uncertain role of different tools for risk assessment and treatment.

Características de la disfunción diastólica en pacientes con insuficiencia renal crónica terminal en hemodiálisis en el Centro Médico Naval en el año 2013 / Characteristics of diastolic dysfunction in patients with terminal chronic renal failure on hemodialysis at the Medical Center Naval in 2013

Objetivos: Determinar las características de la Disfunción Diastólica en pacientes con TRCT en Hemodiálisis en el Centro Médico Naval de Enero a Mayo del 2013. Material y métodos: Se realizó un estudio observacional, analítico, de casos. Se tomaron los datos de acuerdo a la ficha de recolección de datos de 35 pacientes con IRCT en hemodiálisis que acuden regularmente al programa en el periodo que correspondió al estudio. Resultados: La media de la edad de los pacientes con disfunción diastólica e insuficiencia renal crónica terminal fue de 62.2+/-14 años. El 71.4 por ciento de los pacientes tuvieron el antecedente de diabetes mellitus tipo 2. El 77.1 por ciento de los pacientes tuvieron el antecedente de hipertensión arterial. El 57.1 por ciento de los pacientes tuvieron presión diastólica final del ventrículo izquierdo normal. El 51.4 por ciento de los pacientes tuvieron un volumen auricular izquierdo indexado aumentado. El 77.1 por ciento de los pacientes tuvieron disfunción diastólica tipo I, seguido de disfunción diastólica tipo II en un 20 por ciento, siendo menos frecuente la disfunción tipo III con un 2.9 por ciento. Conclusiones: La prevalencia de la disfunción diastólica en pacientes con TRCT en Hemodiálisis fue del 100 por ciento. EI tipo de Disfunción Diastólica más frecuente en pacientes con TRCT en Hemodiálisis fue la tipo I. Hubo una mayor frecuencia de volumen auricular izquierdo indexado aumentado. Hubo una mayor frecuencia de presión de fin de diástole del ventrículo izquierdo normal. El grupo etáreo de 41 a 65 años y el sexo masculino presentan mayor grado de disfunción diastólica.

Objectives: To determine the characteristics of diastolic dysfunction in patients with end-stage renal disease (ESRD) on hemodialysis in the Naval Medical Center from January to May of 2013. Methods and material: Observational and analytic study of cases was performed. The data were taken from the data collection of 35 patients with ESRD on hemodialysis, who regularly attend the program in the period, which corresponded to the study. Results: The mean age of the patients with diastolic dysfunction and end-stage renal disease was 62.2+/-14 years. The 71.4 per cent of the patients had a history of diabetes mellitus type 2. The 77.1 per cent of the patients had a history of high blood pressure. The 57.1 per cent of patients had normal left ventricular end diastolic pressure. The 51.4 per cent of patients had an increased indexing left atrial volume. The 77.1 per cent of patients had diastolic dysfunction type I, type II diastolic dysfunction followed by 20 per cent, being Iess frequent dysfunction type III with a 2.9 per cent. Conclusions: The prevalence of diastolic dysfunction in patients with ESRD on hemodialysis was 100 per cent. Diastolic dysfunction more frequent in patients with IRCT on hemodialysis was the type I. There was a higher frequency of left atrial volume index increased. There was a higher frequency of end of normal left ventricular diastolic pressure. The 41 to 65 years age group and males have higher degree of diastolic dysfunction.

Embolized crospovidone (poly[N-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users.

Crospovidone is an insoluble polymer of N-vinyl-2-pyrrolidone that is used as a disintegrant in pharmaceutical tablets. It can potentially embolize to the lung when aqueous tablet suspensions are injected intravenously. In this report, we identified embolized crospovidone in autopsy-derived lung tissue from three adult IV drug users, 1 man and 2 women, whose ages respectively were 27, 38, and 40 years. Suspected crospovidone was compared with pharmaceutical-grade crospovidone by means of histochemical stains, transmission electron microscopy, and infrared spectroscopy. Similar particles were also observed by light microscopy in a 4-mg tablet of hydromorphone, a preparation prescribed to two of the patients. Two patients had sickle cell disease and were taking methadone and/or hydromorphone for pain management; the third was receiving parenteral hyperalimentation after small bowel resection. Crospovidone appeared as deeply basophilic, coral-like particles within pulmonary arteries and in extravascular foreign-body granulomas. Intrapulmonary crospovidone stained similarly to the pure substance, including intense staining with mucicarmine, Congo red, and Masson trichrome. With Movat pentachrome stain, both intravascular and purified crospovidone appeared orange-yellow, whereas most interstitial particles associated with giant cells stained blue-green. Alcian blue failed to stain intravascular or purified crospovidone but strongly decorated some phagocytized particles. Ultrastructurally, both purified powder and tissue deposits of crospovidone appeared as irregular, electron dense, laminated, and finely granular material. Intrapulmonary crospovidone was associated with inflammatory cells and exhibited degenerative changes. By infrared spectroscopy, crospovidone in tissue had the same spectral characteristics as pharmaceutical grade crospovidone and the library reference, polyvinylpyrrolidone (PVP). We conclude that crospovidone contributes to pulmonary vascular injury in some persons who illicitly inject pharmaceutical tablets. It is readily identifiable histologically and distinguishable from other tablet constituents, such as cornstarch, talc, and microcrystalline cellulose. The variable staining with Alcian blue and Movat suggests that crospovidone is altered in vivo by the inflammatory response.

Pulmonary hypertension in sickle cell hemoglobinopathy: a clinicopathologic study of 20 cases.

Pulmonary hypertension is one of the major causes of morbidity and mortality of patients with sickle cell hemoglobinopathy (SCH). Although a clinically recognized complication of sickle cell disease (SCD), there are few published pathologic studies of pulmonary findings in these patients. The aim of this study was to define the pulmonary pathologic changes and to investigate correlation between the pathologic changes, the antemortem diagnosis of pulmonary hypertension, and the severity of SCH. Cases of SCH were identified from the autopsy database using Snomed codes. Clinical and echocardiograph data were collected for correlation with the pathologic data. A total of 20 adult patients (12 males and 8 females) were identified. Hemoglobin electrophoresis results were available for 16 patients, with hemoglobin S fraction percentages ranging from 23% to 97.8%. Eleven patients had SCD, 5 patients had sickle cell trait (SCT), and the remaining 4 patients without hemoglobin electrophoresis were included in the SCT group. The mean age of the SCT group was higher than that of the SCD group (P = 0.03). Histologically, all 20 patients demonstrated changes in pulmonary vasculature considered diagnostic of pulmonary hypertension grade I to grade IV, associated with plexiform lesions in 60% of patients. Medial hypertrophy and intimal hyperplasia/fibrosis, considered potentially reversible lesions, were seen in all patients. A weak association was found between SCD and plexiform lesions. Fibroelastic degeneration of small arteries, arterioles, and venules was identified in almost all (95%) cases. Clinically, tricuspid regurgitation was detected by echocardiogram in 10 of 20 (50%) patients; 6 of these 10 had significant regurgitation to allow estimation of systolic pressure. Sudden death occurred in 8 patients, with males having a significantly higher incidence. Cardiomegaly was present in 95% of patients, however, autosplenectomy and hepatic cirrhosis/hemochromatosis were observed almost exclusively in patients with SCD. Cirrhosis was found to have a strong positive association with SCD. This study demonstrates pulmonary hypertensive changes in all 20 autopsied patients who had SCH but died from various causes. We conclude that a high prevalence of pulmonary hypertension is associated with SCH with consequent high mortality. Therefore, patients with SCH would benefit from a regular periodic assessment for pulmonary hypertension regardless of age, sex, and severity of hemoglobinopathy.