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INTRODUCTION AND OBJECTIVES: The aim of this study was to compare the prognostic value of TIMI 3 flow versus noninvasive markers of coronary artery reperfusion on the outcome of patients with a recent acute myocardial infarction (AMI) treated with primary angioplasty. PATIENTS AND METHOD We analyzed 172 consecutive patients with AMI and ST-segment elevation, who were treated with primary angioplasty within 12 hours of admission. Mean age was 6113 years, 77% were men, and 56% had a history of previous AMI. RESULTS: In-hospital mortality was 3.6%; 16.6% developed heart failure, and 11.1% had complex arrhythmias during their hospital stay. The noninvasive criterion for successful reperfusion was the presence of two or more markers of reperfusion based on ECG changes or CK levels after angioplasty. Reperfusion was successful in 87.7% of the patients, and TIMI 3 flow was achieved in 87%. There was no significant concordance between the two methods (kappa index = 0.012). Multivariate analysis showed that both successful reperfusion (OR=0.028; 95% CI, 0.003-0.268) and TIMI 3 flow (OR=0.104; 95% CI, 0.019-0.563) were protective for in-hospital mortality. However, in the multivariate analysis only successful reperfusion was a protective factor for heart failure and complex arrhythmias. CONCLUSION: Our findings confirm that both TIMI 3 flow and successful coronary reperfusion evaluated noninvasively show independent prognostic value in patients with AMI treated with primary angioplasty. Noninvasive markers of coronary reperfusion should be used as complementary to angiography in these patients.

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La aterectomía coronaria endovascular representa a un conjunto de técnicas de remoción de placa que fueron altamente utilizadas durante la angioplastia previo a la introducción de stents. En esa época, aunque comparadas con la angioplastia con balón no ofrecían beneficio en cuanto a la incidencia de reestenosis, permitían un procedimiento más seguro que el tratamiento de las lesiones complejas. Sin embargo, posterior al advenimiento de los stents su uso se restringió a situaciones exepcionales. En los últimos años nuevamente se plantea un rol de la aterectomía para ser usada previa al implante de los stents, con el propósito de disminuir la incidencia de reestenosis. Los resultados de los estudios preliminares hasta ahora disponibles sugieren que si bien esta tecnología puede no ser necesaria en la mayoría de los casos, frente a la dilatación de placas seleccionadas que tienen una conocida mayor incidencia de reestenosis, podría ser útil la aterectomía previa al implante de los stents

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Background: The implantation of pacemakers improves cardiac function and quality of life, in particular with dual chamber DDD and DDDR modes. Aim: To evaluate our clinical experience and results on pacemaker implantation, from 1963 to 1998. Material and methods: Computerized data collected from 2,445 consecutive paced patients was reviewed. A total of 3,554 operative procedures were performed, including 412 procedures for complications and 697 pacemaker replacement. Patient survival was determined from clinical records, inquiry to pacemaker manufacturers and death certificates from Servicio de Registro Civil e Identificaci-n de Chile (Chilean Civil and Identification Registry). Results: Use of dual chamber (DDD and DDDR) pacemakers increased progressively up to 74 percent from 1988 to 1998. Complication rate was 42 percent in the 1963-1976 study period, it decreased to 10.6 percent in the 1977-1987 study period, and to 5.6 percent by 1988-1998. Only two patients died during surgery in the study period (0.08 percent). In the 1977-1987 period, pacemakers lasted 10.6 years. Survival rates were 52 percent at ten years, 33 percent at 15 years, and 21 percent at 20 years, with a median survival of 11.7 years, and 7.24 years in patients over 80 years old. Conclusions: Transvenous permanent pacing can be accomplished today with a low complication rate, mainly due to better technology and surgical procedures

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Background: Heart transplantation currently provides the most effective treatment for advanced heart failure. However, medical therapy for this condition has also improved, heart donors are scarce and the cost of the procedure is high. Therefore the indications and management of these patients need reevaluation. Aim: To analyze the results of 24 patients submitted to heart transplantation for end-stage heart failure needing repeated hospitalizations and i.v. inotropes for compensation. Patients and methods: The group was comprised by 21 men and 3 women with a mean age of 36.8 years, mean left ventricular ejection fraction 19ñ4.5 percent, mean systolic pulmonary artery pressure 48ñ13 mmHg (24-70) and mean pulmonary vascular resistance 2.6 Wood Units (1-5). Fourteen patients (58 percent) had a previous median sternotomy. Immunosupression did not include induction therapy and steroids were discontinued early...

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Background: Unstable angina is characterized by angina at rest, angina of recent onset or accelerating angina. It is caused by a fissure or ulceration of an atheromatous plaque leading to thrombi formation and coronary spasm. Aim: To report the immediate and late results of coronary angioplasty in patients with unstable angina. Patients and methods: Eight hundred twenty eight patients were subjected to coronary arteriography between January 1994 and June 1996. Of these, 242 were subjected to a transluminal coronary angioplasty, 245 patients were subjected to surgical revascularization and 341 patients were treated without revascularization. Results: A total of 323 stenotic lesions (1.3 lesions per patient) were subjected to angioplasty. Angiographic success was obtained in 93 percent of patients. Angiographic success and lack of major complications such as death, infarction of the need for surgery, was obtained in 90 percent of patients. Five patients (2.1 percent) had a non fatal infarction and five required emergency surgery. Hospital mortality was 1.2 percent. During the year of follow up, 15 percent required a new revascularization, 3.3 percent had a non fatal infarction and 3.3 percent died. Conclusions: Coronary angioplasty had a 90 percent immediate success and 78 percent of patients were free of ischemic events after one year of follow up

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Background: The use of Rotablator in percutaneous transluminal coronary angioplasty attempts to reduce the atheromatous plaque abrading it and fragmenting the pariental calcium of the artery. Aim: To report our experience with the use of Rotablator: Patients and methods: Rotational atherectomy was performed in 189 patients aged 60.8 ñ 11 years (154 men). The clinical indication for the procedure was chronic angina in 22 percent, unstable angina in 44 por ciento, myocardial infarction in 21 percent, silent angina in 7 percent and re-stenosis in 6 percent. One bundred seventy seven patiens were followed for a mean of 15.9 ñ 6.3 months. Results: Two hundred thirty six stenoses in 215 coronary arteries were treated with a 98.7 percent angiographic success rate. One patient had a Q infarction and no patient died or required emergency surgery. Fourteen patients had rises in CK MB enzymes (non Q infarction). Thee patients had a pseudoaneurism and three had bleedings that required transfusion. Of the followed patients, 33 had a clinically suspected re-stenosis, that was angiographically confirmed in 23. Cardiac mortality was 2.3 percent. Seventy nine percent of patients had an evolution without angina or coronary events. Conclusions: Percutaneous transluminal coronary angioplasty with the use of Rotablator had a high immediate success rate and a low incidence of complications. The clinical evolution of patients has been favorable with a low incidence of mortality and ischemic events

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DR. YOVANOVICH: Como conclusión, podemos decir que dentro de la variedad de presentaciones clínicas de la angina inestable, las de peor pronóstico son aquellas que aparecen en reposo, las que ocurren después de un infarto, y desde luego aquellas que, pese al tratamiento, no logran ser controladas. El electrocardiograma es un examen muy útil en la estratificación: la presencia de ascensos transitorios del ST y/o cambios de la onda T, especialmente cuando ocurren en la pared anterior, o bien, la presencia de infradesnivel de 2 o más mm en la pared anterior, representan grupos de pacientes de alto riesgo. En cuanto al tratamiento, los pilares básicos son el uso de aspirina, nitroglicerina y beta bloqueadores. Deberá adicionarse heparina en dosis de anticoagulación en los casos en que haya cambios electrocardiográficos, o angina clínicamente de mayor riesgo (dolor en reposo, episodios de dolor en las horas precedentes al diagnóstico, angina postinfarto). El estudio coronariográfico, que se realiza idealmente una vez controlado el cuadro agudo, tiene indicación absoluta en los pacientes con marcadores clínicos o electrocardiográficos de severidad, y relativa en el resto. Estos últimos pueden ser sometidos a pruebas de provocación de isquemia antes del alta hospitalaria, lo que permite definir la conducta posterior. En los centros que tienen como estrategia el estudio invasivo en todos los pacientes con angina inestable, actualmente se utiliza la angioplastia como tratamiento en el 30 por ciento de los casos, cirugía en el 40 por ciento, y tratamiento médico en el 30 por ciento restante, siendo la aspirina el fármaco de indicación común a todos ellos por tiempo indefinido

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Reperfusion therapy has contributed to decreased morbidity and mortality in patients with acute myocardial infarction (AMI). Implementation of thrombolytic therapy, primary angioplasty and emergency coronary artery by-pass surgery have proved to be effective in well designed controlled clinical trials. There is little information, however about the impact of reperfusion therapy in the general clinical population that is usually seen in the coronary care unit. In this paper we have compared the clinical course, morbidity and mortality of patients attended for a first AMI in 2 different periods. Multivariate analysis showed that age and heart failure were significant independent predictors of mortality in both periods. Thus, there has been a significant change in the therapeutic approach to AMI patients in recent years. Widespread utilization of reperfusion therapy appears to be associated with decrease in morbidity and mortality in a general population of patients with a first AMI

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Hay cierta incertidumbre referente a las diferencias en resultados de acuerdo al grado de daño preexistente de la válvula mitral en pacientes sometidos a valvulotomía percutánea con el balón de Inoue. Analizamos nuestra serie consecutiva de 126 pacientes (88 por ciento mujeres) tratadas con este procedimiento desde abril de 1990 a diciembre de 1994. Todos los pacientes tuvieron un área valvular mitral (AVM, método de hemipresión por Doppler)< 1,5 cm² e insuficiencia mitral ausente o menor de grado 2/4. El mismo ecocardiografista determinó el AVM antes y 24 a 48 horas después del procedimiento. En 71 por ciento de los pacientes se efectuó una nueva medición del AVM 12 ñ 1 meses después de la valvuloplastía. La valvuloplastía falló en 5 pacientes: no se pudo cruzar la válvula mitral en 3, 1 paciente falleció durante el procedimiento y 2 tuvieron tamponamiento cardiaco tratado por cirugía de emergencia con comisurotomía quirúrgica en el mismo acto. En los 121 pacientes restantes (96 por ciento), la presión media de aurícula izquierda disminuyó de 20 ñ 6 (DS) a 11 ñ 5 mmHg (p <0,001) y el AVM aumentó de 0,96 ñ 0,16 a 1,80 ñ 0,33 cm² (p <0,001). Cuatro de los 5 casos fallidos tenían puntaje de Wilkins ò 10. En 99 pacientes con puntaje £ 7, el AVM aumentó 98 ñ 40 por ciento, en tanto que en 22 pacientes con puntaje de 8 ó 9 el AVM aumentó 79 ñ 41 por ciento (p <0,05). Tres pacientes entre los primeros y 1 entre los segundos desarrollaron insuficiencia mitral ò 3/4. Se observó una disminución leve del AVM en el control efectuado 1 año después de la valvuloplastía (1,83 ñ 0,27 a 1,73 ñ 0,29 cm²). Concluimos que la valvuloplastía mitral percutánea con el balón de Inoue es segura y efectiva en pacientes bien seleccionados (puntaje de Wilkins menor de 10). Los pacientes con puntaje > 7 tienen resultados menos favorables que aquellos con puntajes menores

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