Optimización de la detección de fibrilación auricular subclínica tras un ESUS / Optimizing the detection of subclinical atrial fibrillation after ESUS

Introducción: Se ha estimado que aproximadamente el 20% de los ictus isquémicos tiene un origen cardioembólico y que no se detecta la causa o que puede haber más de una en el 9-25% de ellos. Un proceso diagnóstico adecuado de ESUS permitiría optimizar el tratamiento antitrombótico. Objetivo: Revisión bibliográfica sobre la evidencia disponible acerca de la mejor aproximación diagnóstica y terapéutica de los pacientes con ESUS y cómo optimizar la detección de la posible fibrilación auricular como causa. Desarrollo: Se realizó una búsqueda a través de PubMed (MEDLINE), mediante los términos MeSH [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Se seleccionaron publicaciones originales de ensayos clínicos, y estudios prospectivos, retrospectivos y de revisión. Conclusiones: La detección de fibrilación auricular tras un ESUS es fundamental para optimizar el tratamiento. Sin embargo, no todos los pacientes tienen el mismo riesgo de presentar fibrilación auricular silente. Existen determinados factores que incrementan este riesgo (dilatación de la aurícula izquierda, edad avanzada, extrasistolia supraventricular frecuente). En estos pacientes, una monitorización más prolongada permitiría aumentar las posibilidades de diagnóstico de la fibrilación auricular y, por lo tanto, beneficiarse, en mayor medida, del tratamiento anticoagulante para evitar ictus recurrentes.(AU)

Introduction: It has been estimated that approximately 20% of ischemic strokes have a cardioembolic origin and the cause is not detected or there are more than one in 9-25% of ischemic strokes. An adequate diagnostic approach of ESUS would allow an optimization of antithrombotic treatment. Objective: Narrative update about the available evidence on the best diagnostic and therapeutic approach among patients with ESUS and how to optimize the detection of atrial fibrillation as a potential cause is reviewed. Development: A search was conducted on PubMed (MEDLINE), using the MeSH terms [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Conclusions: The detection of atrial fibrillation after ESUS is mandatory to optimize the treatment. However, not all patients have the same risk of developing silent atrial fibrillation. There are some factors that increase this risk (left atrium enlargement, elderly, frequent premature supraventricular complexes). In these patients, a more prolonged monitorization could increase the possibility of detecting atrial fibrillation, and consequently, to benefit more from anticoagulant treatment.(AU)

[Optimizing the detection of subclinical atrial fibrillation after ESUS]. / Optimización de la detección de fibrilación auricular subclínica tras un ESUS.

INTRODUCTION: It has been estimated that approximately 20% of ischemic strokes have a cardioembolic origin and the cause is not detected or there are more than one in 9-25% of ischemic strokes. An adequate diagnostic approach of ESUS would allow an optimization of antithrombotic treatment. OBJECTIVE: Narrative update about the available evidence on the best diagnostic and therapeutic approach among patients with ESUS and how to optimize the detection of atrial fibrillation as a potential cause is reviewed. DEVELOPMENT: A search was conducted on PubMed (MEDLINE), using the MeSH terms [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Original data from clinical trials, prospective and retrospective studies and reviews were selected. CONCLUSIONS: The detection of atrial fibrillation after ESUS is mandatory to optimize the treatment. However, not all patients have the same risk of developing silent atrial fibrillation. There are some factors that increase this risk (left atrium enlargement, elderly, frequent premature supraventricular complexes). In these patients, a more prolonged monitorization could increase the possibility of detecting atrial fibrillation, and consequently, to benefit more from anticoagulant treatment.

TITLE: Optimización de la detección de fibrilación auricular subclínica tras un ESUS.Introducción. Se ha estimado que aproximadamente el 20% de los ictus isquémicos tiene un origen cardioembólico y que no se detecta la causa o que puede haber más de una en el 9-25% de ellos. Un proceso diagnóstico adecuado de ESUS permitiría optimizar el tratamiento antitrombótico. Objetivo. Revisión bibliográfica sobre la evidencia disponible acerca de la mejor aproximación diagnóstica y terapéutica de los pacientes con ESUS y cómo optimizar la detección de la posible fibrilación auricular como causa. Desarrollo. Se realizó una búsqueda a través de PubMed (MEDLINE), mediante los términos MeSH [ESUS] + [atrial fibrillation] + [diagnosis] + [treatment]. Se seleccionaron publicaciones originales de ensayos clínicos, y estudios prospectivos, retrospectivos y de revisión. Conclusiones. La detección de fibrilación auricular tras un ESUS es fundamental para optimizar el tratamiento. Sin embargo, no todos los pacientes tienen el mismo riesgo de presentar fibrilación auricular silente. Existen determinados factores que incrementan este riesgo (dilatación de la aurícula izquierda, edad avanzada, extrasistolia supraventricular frecuente). En estos pacientes, una monitorización más prolongada permitiría aumentar las posibilidades de diagnóstico de la fibrilación auricular y, por lo tanto, beneficiarse, en mayor medida, del tratamiento anticoagulante para evitar ictus recurrentes.

Rehabilitación domiciliaria en el tratamiento postoperatorio de la reparación de los tendones flexores / Home-based rehabilitation in the postoperative treatment of flexor tendon repair

Objetivo. Evaluar resultados y complicaciones de la reparación de tendones flexores en un programa de rehabilitación domiciliario sin la asistencia de un terapeuta de mano durante las primeras 4semanas postoperatorias. Material y métodos. Entre julio de 2009 y julio de 2014, un total de 21 dedos en 15 pacientes fueron tratados en nuestro centro por una lesión completa de tendones flexores en la zona del sistema de poleas (zonas 1 y 2). Ejercicios pasivos y activos de rehabilitación, ejecutados por el propio paciente, se empezaron la mañana siguiente a la operación. Los datos de movilidad y complicaciones fueron recogidos 6meses después de la intervención. Resultados. Quince dedos tuvieron recuperación completa de la flexión. Un paciente sufrió una rotura en la quinta semana postoperatoria. En 10 de los 21 dedos se presentó una contractura en flexión de la articulación interfalángica proximal; en 5 la contractura fue de 10° o menos, sin afectar la función ni la estética. Discusión. La terapia de mano especializada ha sido de gran importancia en el tratamiento postoperatorio de las dolencias de la mano. Desafortunadamente, en nuestro medio, es frecuente que estos profesionales no estén disponibles en los primeros días tras la intervención. Con este protocolo, el paciente asume la responsabilidad en la ejecución de los ejercicios, lo que podría conllevar un peor resultado final y un aumento en la tasa de roturas. Conclusión. El programa de rehabilitación domiciliaria proporcionó la recuperación completa de la movilidad articular en la mayoría de los casos, con un bajo número de complicaciones (AU)

Objective. To evaluate the results and complications of flexor tendon repair in which a home-based rehabilitation program was utilized without the assistance of a hand therapist during the first 4postoperative weeks. Material y methods. Between July 2009 and July 2014, a total of 21 digits in 15 patients were treated in our institution for complete laceration of the flexor tendons within the flexor pulley system (zone 1 and 2). Passive and active exercises performed by the patients themselves were started the morning after the operation. Data, as range-of-motion and complications, were collected 6months after the surgery. Results. Fifteen digits had full recovery of flexion. One patient suffered a rupture in the fifth postoperative week. Ten of the 21 digits developed a flexion contracture of the proximal interphalangeal joint; in 5 the contracture was less or equal to 10° without impairment of function or aesthetics. Discussion. Over recent decades, specialized hand therapy has been of great importance in the postoperative treatment of hand diseases. Unfortunately, these professionals are not always available in our area in the first days after surgery. With this protocol, the patient is in charge of carrying out the postoperative exercises, which could lead to a worse final result and a higher rate of complications. Conclusion. The home-based rehabilitation program yielded complete recovery of joint mobility in most cases with a low complication rate (AU)

Home-based rehabilitation in the postoperative treatment of flexor tendon repair. / Rehabilitación domiciliaria en el tratamiento postoperatorio de la reparación de los tendones flexores.

OBJECTIVE: To evaluate the results and complications of flexor tendon repair in which a home-based rehabilitation program was utilized without the assistance of a hand therapist during the first 4postoperative weeks. MATERIAL Y METHODS: Between July 2009 and July 2014, a total of 21 digits in 15 patients were treated in our institution for complete laceration of the flexor tendons within the flexor pulley system (zone 1 and 2). Passive and active exercises performed by the patients themselves were started the morning after the operation. Data, as range-of-motion and complications, were collected 6months after the surgery. RESULTS: Fifteen digits had full recovery of flexion. One patient suffered a rupture in the fifth postoperative week. Ten of the 21 digits developed a flexion contracture of the proximal interphalangeal joint; in 5 the contracture was less or equal to 10° without impairment of function or aesthetics. DISCUSSION: Over recent decades, specialized hand therapy has been of great importance in the postoperative treatment of hand diseases. Unfortunately, these professionals are not always available in our area in the first days after surgery. With this protocol, the patient is in charge of carrying out the postoperative exercises, which could lead to a worse final result and a higher rate of complications. CONCLUSION: The home-based rehabilitation program yielded complete recovery of joint mobility in most cases with a low complication rate.

Experiencia con el colgajo interóseo posterior: serie de casos / Experience with posterior interosseous flaps: a cases series

Objetivo. Se describen diez pacientes intervenidos para coberturas de heridas traumáticas y retracciones cicatriciales las cuales se realizaron con un colgajo interóseo posterior. Material y método. Diez pacientes consecutivos, que fueron programados para coberturas de heridas entre marzo de 2007 y abril de 2010, se revisaron retrospectivamente en cuanto a factores demográficos, etiología, localización de las heridas, dimensiones del colgajo, resultado final y complicaciones. Resultados. Se descartó un paciente por encontrarse variaciones anatómicas. De los nueve restantes, la supervivencia fue total en siete y parcial (pérdida del 10% de la extremidad opuesta al pedículo) en dos. En los tres primeros casos de la serie se apreció una congestión venosa leve a moderada que no comprometió el resultado final. Discusión. Es nuestra preferencia prescindir del uso de colgajos libres para disminuir el tiempo de intervención y evitar complicaciones derivadas de la realización de anastomosis. La incorporación de una vena subcutánea de gran calibre disecada con tejido subcutáneo realizada a partir del cuarto caso solucionó los problemas de edemas por congestión venosa. El injerto de piel parcial en la zona donante puede llevar a quejas estéticas. Conclusión. El colgajo interóseo posterior demostró ser una alternativa fiable y efectiva para cobertura de heridas que se localicen en el rango de alcance de su pedículo, a menos que se encuentren variaciones anatómicas, lo cual ocurre en pocos casos (AU)

Objectives. To describe 10 patients treated for traumatic wounds or scar tissue retraction with reversed pedicled posterior interosseous flaps. Material and methods. Ten consecutive patients, operated on for wound coverage between March 2007 and April 2010, were retrospectively reviewed in terms of demographic factors, etiology, wound location, flap dimensions, final outcome, and complications. Results. One patient was excluded due to anatomical variations. From the remaining nine patients, full flap survival was achieved in seven; partial survival (10% flap loss at the distal end opposite to the pedicle) was achieved in two. Slight to moderate venous congestion was observed in the three first patients of this series, but this did not affect the final outcome. Discussion. It is our preference to avoid the use of free flaps in order to decrease the operation time and to avoid complications related to the anastomosis technique. The addition of a large subcutaneous vein dissected with subcutaneous tissue, which we started in the fourth case, solved the problems related to edemas and venous congestion. Split thickness skin grafts on the donor area can lead to aesthetic complaints. Conclusion. Posterior interosseous flap was shown to be a reliable and effective alternative for wound coverage within the range of its pedicle, unless there are anatomical variations, which is not common (AU)

Cirugía del aneurisma de aorta abdominal en pacientes octogenarios / Surgical treatment of abdominal aortic aneurysm in octogenarian patients

Objetivo: Analizar las características de los pacientes octogenarios sometidos a cirugía convencional y valorar la experiencia y los resultados de este tipo de tratamiento en nuestro servicio. Pacientes y métodos. Estudio retrospectivo de todos los pacientes consecutivos mayores de 80 años con un aneurisma de aorta abdominal (AAA) tratados de forma quirúrgica convencional desde enero de 1993 hasta diciembre de 2006 en nuestro centro. Resultados. Se incluyeron 45 pacientes con una edad media de 83,4 +/- 3,4 años. La mayoría eran varones (40 pacientes, 88,9%). Veintiocho pacientes (62,2%) fueron clasificados como ASA (Asociación Americana de Anestesiología) IV. La media del diámetro de los AAA fue de 6,9 +/- 2 cm. Se trató de forma urgente a 29 pacientes (64,4), de los cuales, en 22 casos, la indicación fue por rotura aneurismática. Destacó entre los factores de riesgo cardiovascular la hipertensión, presente en 30 pacientes (66,7%). Treinta y un pacientes (68,9%) padecían alguna cardiopatía. La mortalidad operatoria fue del 6,3% en los pacientes tratados de forma electiva, mientras que en los tratados de forma urgente la mortalidad ascendió a 41,4% (p=0,01). La presencia de ictus previo (11,1%) a la intervención quirúrgica se asoció a mayor mortalidad (p=0,02). Conclusiones. Basándonos en estos resultados, el tratamiento quirúrgico electivo de los pacientes octogenarios parece justificado en nuestro centro cuando no existe una opción terapéutica alternativa menos invasiva

Aims. To analyse the characteristics of octogenaria patients submitted to conventional surgery and to evaluate our experience and the outcomes of this type of treatment in our department. Patients and methods. We conducted a retrospective study of all the consecutive patients over 80 years of age with an abdominal aortic aneurysm (AAA)who were treated using conventional surgery at our health centre beween January 1993 and December 2006. Results. The sample was made up of 45 patients, with a mean age of 83.4 +/- 3.4 years, most of whom were males (40 patients, 88.9%). Twenty-eight patiens (62.2%) were classified as ASA (American Society of Anaesthesiology) IV. The mean diameter of the AAA was 6.9 +/- 2 cm. The aneurysm was treated urgently in 29 patients (64.4%), and in 22 of these cases the indication was due to aneurismal rupture. The most common cardiovascular risk factor was hypertension, which was present in 30 patients (66.7%). Thirty-one patients (68.9%) had some kind of heart disease. The operative mortality rate was6.3% in patients treated electively, whereas among those treated urgently the mortality rate rose to 41.4% (p=0.01). The presence of a stroke (11.1%) prior to the surgical intervention is associated to a higher mortality rate (p=0.01). The presence of a stroke (11.1%) prior to the surgical intervention is associated to a higher mortality rate (p=0.02). Conclusions. On the basis of these results, elective surgical treatment in octogenarian patients seems to be justified in our health centre when no other less invansive therapeutic alternative is available

Síndrome Tako-Tsubo simulando infarto agudo de miocardio / Tako-Tsubo syndrome mimicking acute myocardial infarction

El síndrome Tako-Tsubo o de discinesia apical transitoria (SDAT) o “apical ballooning” se describió por primera vez en la década de los años noventa en Japón. Como entidad clínica existe desde el año 2001 con la publicación de una serie de 88 casos. La etiopatogenia de este síndrome está aun por definir. El diagnóstico diferencial con un infarto agudo de miocardio (IAM) se realiza mediante coronariografía urgente y es fundamental para el tratamiento y pronóstico que son muy diferentes del IAM. Presentamos un caso del síndrome Tako-Tsubo en una mujer de 72 años. Clínicamente se manifestó como un síndrome coronario agudo (SCA) con infarto agudo de miocardio (IAM) anterior. Se trasladó para angioplastia coronaria transluminal percutánea (ACTP) mostrando coronarias sin lesiones. El curso clínico posterior fue favorable, resolviéndose todas las alteraciones espontáneamente y sin secuelas (AU)

The Tako-Tsubo syndrome, transient apical dyskinesia syndrome or “apical ballooning” syndrome was first described in Japan in the 1990s. It has been recognised as a clinical entiry since 2001, when a series of 88 cases was published. The aetiopathogenesis of this syndrome has yet to be defined. The differential diagnosis to acute myocardial infarction is based on the results of emergency coronary angiography and is fundamental for a correct management and prognosis, which are quite different from those for acute myocardial infarction. We report one case of Tako-Tsubo syndrome in a 72- year-old female. The patient was initially diagnosed of acute coronary syndrome with acute anterior myocardial infarction; she was referred for percutaneous transluminal coronary angioplasty, at which time lesion- free coronary arteries were demonstrated. The ensuing clinical evolution was favourable, all changes resolving spontaneoulsy and without sequelae (AU)

[Maze technique for the treatment of auricular fibrillation: initial experience]. / Técnica de MAZE para el tratamiento de la fibrilacion auricular: experiencia inicial.

INTRODUCTION AND OBJECTIVES: The MAZE procedure was developed as a surgical approach to the management of patients with atrial fibrillation refractory to medical treatment. This study seeks to identify the risk and benefits of adding the MAZE procedure in patients with atrial fibrillation undergoing surgery for underlying organic cardiac disorders. MATERIAL AND METHODS: Since november 1993, we have performed 10 interventions with the MAZE procedure, for the treatment of refractory atrial fibrillation. The indication to perform the technique was systemic embolism in 5 patients, contraindication for the anticoagulant treatment in two cases and no response to antiarrhythmic treatment in 5 cases. Two patients had more than one indication. In all the cases another surgical procedure was performed, 5 replacements of mitral valve, a mitral repair, one tricuspid repair and tree repairs of an atrial septal defect. RESULTS: Soon after surgery 9 patients were in sinus rhythm, and one in atrial fibrillation. Four patients needed atrial pacing during the first days. One patient required a pacemaker due to symptomatic sinus bradycardia. During the first 3 months, 4 patients had episodes of paroxysmal atrial fibrillation and flutter. One patient died suddenly one month after surgery. Seven patients have completed two years of follow-up, and are in stable sinus rhythm, in functional class I and free of antiarrhythmic drugs. All of them have echocardiographic evidence of mechanical activity in both atria. Left atrium had been reduced from 5.3 +/- 0.7 cm to 4.5 +/- 0.7 cm (p < 0.05). No patient has presented new embolic events. CONCLUSIONS: The MAZE procedure is a good choice in selected patients with atrial fibrillation refractory to medical treatment, or a precedent of systemic embolism. However, several problems can complicate the patient's course.

[Experimental endocarditis. Pathological anatomy of human endocarditis]. / Endocarditis experimental. Anatomía patológica de la endocarditis humana.

Experimental reproduction of human endocarditis in animal models has been based on the induction of structural lesions in valve endocardium using different methods. The primary lesion caused in this way is the so called non-bacterial thrombotic endocarditis. Its colonization is then induced by inoculation of microorganisms in the bloodstream. Freedman's modified method has been the most widespread model of this type. It has mainly been performed in rabbits with inoculation of Staphylococcus aureus or alpha-hemolitic Streptococcus. Experimental models of endocarditis have contributed to our knowledge of the pathogenic mechanisms, causative agents and predisposing factors of endocarditis. They have also allowed us to develop appropriate diagnostic, therapeutic and prophylactic measures for its management.

VDD pacing with single lead in a heart transplant recipient: case report.

Permanent pacemaker implantation is required in a large number of transplantation patients principally because of sinus node dysfunction of the donor atrium. The most suitable mode of pacing in these cases is still subject to controversy. We describe one case of a single lead system of VDD stimulation and sensing of the recipient atrial signal in a 32-year-old patient with posttransplant symptomatic sinus node dysfunction. Physiological adaptation of rate was achieved with recovery of normal receptor sinus node function.