Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

Inflamación y placa inestable / Inflammation and plaque instability

The mechanisms that regulate the stability of the atheroma plaque are a new focus of interest to understand the pathophysiology of acute coronary syndromes (ACS) and its therapy. Up to 75% of ACS are clinical expression of an unstable plaque rupture. The identification of unstable or so called vulnerable plaque (VP) became an interesting target, since they are the substrate of eventual future events. The VP determinant factors are: the size and consistence of lipid core, thickness of fibrous cap around this core, and the balance inflammation- reparation inside this cap. Inflammation plays a starring role in every single atherosclerosis stage. High sensitivity C - reactive protein (hs-CRP) is one of the most used markers of inflammation. We determined hs-CRP in 104 patients. The elevation of this marker was 5.85 mg/L in stable angina, 19.92 in non ST elevation ACS, and 50.41 mg/L in whom that presented ACS with ST elevation. (p < 0.01). The majority of coronary occlusion occurs in previously non-significant (< 70%) angiographic stenosis. Therefore, the current challenge is to identify and treat VP using whether invasive or non-invasive methods. This lead to a new concept: the [quot ]vulnerable patient[quot ]. Using these new diagnostic techniques, along with the information obtained from clinical trials in course, we should be able to prevent future coronary events.

[Inflammation and plaque instability]. / Inflamación y placa inestable.

The mechanisms that regulate the stability of the atheroma plaque are a new focus of interest to understand the pathophysiology of acute coronary syndromes (ACS) and its therapy. Up to 75% of ACS are clinical expression of an unstable plaque rupture. The identification of unstable or so called vulnerable plaque (VP) became an interesting target, since they are the substrate of eventual future events. The VP determinant factors are: the size and consistence of lipid core, thickness of fibrous cap around this core, and the balance inflammation- reparation inside this cap. Inflammation plays a starring role in every single atherosclerosis stage. High sensitivity C - reactive protein (hs-CRP) is one of the most used markers of inflammation. We determined hs-CRP in 104 patients. The elevation of this marker was 5.85 mg/L in stable angina, 19.92 in non ST elevation ACS, and 50.41 mg/L in whom that presented ACS with ST elevation. (p < 0.01). The majority of coronary occlusion occurs in previously non-significant (< 70%) angiographic stenosis. Therefore, the current challenge is to identify and treat VP using whether invasive or non-invasive methods. This lead to a new concept: the "vulnerable patient". Using these new diagnostic techniques, along with the information obtained from clinical trials in course, we should be able to prevent future coronary events.

[Diagnosis by magnetic resonance imaging of a case of intramural left atrial hematoma]. / Hematoma intramural auricular izquierdo diagnosticado por resonancia magnética nuclear.

We report a case of spontaneous intramural left atrial hematoma with chest pain and pulmonary edema as the primary clinical manifestations. Echocardiographic techniques revealed obstruction of the left atrial cavity by cyst-like masses attached to the posterior and anterior atrial wall. A large intramural hematoma due to extensive atrial wall dissection was observed by magnetic resonance imaging. Surgery confirmed the diagnosis of intramural left atrial hematoma with no complications. We review the clinical and diagnostic profile of the three cases of spontaneous intramural left atrial hematoma reported in the world medical literature.

Hematoma intramural auricular izquierdo diagnosticado por resonancia magnética nuclear / Diagnosis by magnetic resonance imaging of a case of intramural left atrial hematoma

Presentamos el caso de una paciente con hematoma intramural auricular izquierdo espontáneo que se manifestó con dolor torácico y edema pulmonar. Las técnicas ecocardiográficas objetivaron obstrucción al flujo auricular producido por masas de aspecto quístico en la pared posterior y anterior de la aurícula izquierda. Las imágenes con resonancia magnética demostraron un gran hematoma mural producido por disección extensa de la pared auricular. El diagnóstico de hematoma intramural se confirmó en una intervención quirúrgica sin complicaciones. Se revisa el perfil clínico y diagnóstico de los tres casos de hematomas intramurales espontáneos comunicados en la bibliografía (AU)

Trombosis valvular protésica: ¿cuál es la terapia inicial más apropiada? / Prosthetic valve thrombosis: what is the most appropriate initial therapy?

Introducción y objetivos. Este estudio pretende investigar cuál es la mejor terapia inicial para los pacientes que sufren una trombosis protésica obstructiva. Métodos. Se analizaron los datos históricos de 47 pacientes que en un período de 8 años habían sido diagnosticados de trombosis protésica en 2 hospitales terciarios. Resultados . Las prótesis afectadas eran mitrales en 34 casos (2 biológicas), aórticas en 12 y doble prótesis mitroaórtica en uno. En 12 casos la trombosis no producía obstrucción. En los 35 restantes, la obstrucción protésica fue tratada con heparina (n = 2), trombólisis (n = 19) o cirugía (n = 14). Todos los enfermos del grupo de trombólisis sobrevivieron a la hospitalización, si bien seis necesitaron ser operados antes del alta por persistencia de un gradiente elevado (n = 5) o anomalías en el desplazamiento de un disco (n = 1). Cinco de los 14 pacientes del grupo de cirugía directa fallecieron, dos antes de que la operación pudiera llevarse a efecto. En consecuencia, la tasa de mortalidad, examinada bajo el prisma de intención de tratar, fue muy favorable para la trombólisis (p = 0,008), y ello a pesar de que el índice de gravedad (en una escala de 0 a 4) era superior en este grupo: 3,3 ñ 0,6 frente a 2,1 ñ 0,9 en los pacientes del grupo de cirugía directa; p < 0,0001. Conclusiones. La trombólisis, en términos de mortalidad hospitalaria, constituye una alternativa mejor que la cirugía directa para combatir la obstrucción trombótica protésica. Aun cuando el resultado pueda resultar subóptimo, permite operar al paciente en mejores condiciones clínicas y, por tanto, con un menor riesgo (AU)