RESUMEN
OBJECTIVE: We sought to determine the prognostic value of qualitative and quantitative analysis obtained by real-time myocardial perfusion echocardiography (RTMPE) in patients with known or suspected coronary artery disease (CAD). BACKGROUND: Quantification of myocardial blood flow reserve (MBFR) in patients with CAD using RTMPE has been demonstrated to further improve accuracy over the analysis of wall motion (WM) and qualitative analysis of myocardial perfusion (QMP). METHODS: From March 2003 to December 2008, we prospectively studied 168 patients with normal left ventricular function (LVF) who underwent dobutamine stress RTMPE. The replenishment velocity reserve (ß) and MBFR were derived from RTMPE. Acute coronary events were: cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization. RESULTS: During a median follow-up of 34 months (5 days to 6.9 years), 17 acute coronary events occurred. Abnormal ß reserve in ≥2 coronary territories was the only independent predictor of events hazard ratio (HR) = 21, 95% CI = 4.5-99; p<0.001). Both, abnormal ß reserve and MBFR added significant incremental value in predicting events over qualitative analysis of WM and MP (χ2 = 6.6 and χ2 = 24.6, respectively; p = 0.001 and χ2 = 6.6 and χ2 = 15.5, respectively; p = 0.012, respectively). When coronary angiographic data was added to the multivariate analysis model, ß reserve remained the only predictor of events with HR of 21.0 (95% CI = 4.5-99); p<0.001. CONCLUSION: Quantitative dobutamine stress RTMPE provides incremental prognostic information over clinical variables, qualitative analysis of WM and MP, and coronary angiography in predicting acute coronary events.
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Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Ecocardiografía de Estrés/métodos , Infarto del Miocardio/diagnóstico por imagen , Pronóstico , Anciano , Medios de Contraste/administración & dosificación , Enfermedad de la Arteria Coronaria/fisiopatología , Dobutamina/administración & dosificación , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Imagen de Perfusión Miocárdica/métodos , Valor Predictivo de las Pruebas , Función Ventricular Izquierda/fisiologíaRESUMEN
Brugada syndrome in a patient with Wolff-Parkinson-White syndrome. We report a 32-year-old man with orthodromic atrioventricular (AV) reciprocating tachycardia using a right posterior accessory pathway. However, his ECG showed ST segment elevation in leads V1 to V3. After successful radiofrequency ablation of his accessory pathway a cardioverter defibrillator was implanted.
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Vías Nerviosas/anomalías , Fibrilación Ventricular/complicaciones , Síndrome de Wolff-Parkinson-White/complicaciones , Adulto , Humanos , Masculino , Vías Nerviosas/fisiopatología , Síndrome , Fibrilación Ventricular/fisiopatología , Fibrilación Ventricular/terapia , Síndrome de Wolff-Parkinson-White/fisiopatología , Síndrome de Wolff-Parkinson-White/terapiaRESUMEN
BACKGROUND: The use of balloon-expandable stents provides an effective alternative therapy in patients with stenotic lesions in congenital heart disease. Stents implantation has served to improve the results and to reduce complications of balloon angioplasty for coarctation and recoarctation of the aorta. OBJECTIVE: We report our results after primary stents implantation for coarctation and recoarctation of the aorta. PATIENTS AND METHODS: Balloon-expandable stents were implanted in 14 patients (mean age 20 +/- 12 years) with coarctation of the aorta (11 native and 3 postoperative); 2 patients had associated malformations. The morphology varied: 10 resembled a located-diaphragm (one of them with moderate arch hypoplasia); 2 had distorted coarctation and 2 had a complete aortal obstruction. Five patients were hypertensive and 1 had cardiogenic shock and severe arrhythmias which did not respond to intensive medical therapy. In all cases 14 Palmaz stents (7 P308 and 7 P4014) were implanted with the primary technique through a Mullin's sheath. The balloon-to-descending aorta diameter ratio, measured at the level of the diaphragm, was 1. A special technique was carried out in the 2 cases with complete aortal obstruction. RESULTS: The procedure was effective in all 14 cases. The coarctation diameter increased from 4 +/- 2 to 15 +/- 2 mm (p < 0.0001) and transcoarctation systolic pressure gradient decreased from 43 +/- 19 to 2 +/- 2 mmHg (p < 0.0001). The ratio of the coarctation to descending aorta diameter measured at the level of the diaphragma increased from 0.3 +/- 0.1 to 0.95 +/- 0.05 (p < 0.001). At 19 +/- 8 months follow up, all patients showed sustained clinical improvement. The patient with complete aortal obstruction experienced a dramatic improvement, but she died from a sudden cardiac event 22 months after the procedure. At angiographic follow up in 7 patients, 1 year after implantation, no recoarctation was observed with secondary vessels patent, and absence of restenosis. CONCLUSIONS: a) Percutaneous endovascular stents implantation in coarctation and recoarctation of the aorta may become an effective treatment modality in the older child, adolescent and adults; b) stents are particularly attractive in those patients with a more complex anatomy and higher surgical risk; c) primary stenting is expected to have a lower rate of complications, and d) we describe a special technique with a right femoral-left humeral arterial circuit that is successfully applied to patients with complete aortal obstruction.
Asunto(s)
Coartación Aórtica/cirugía , Stents , Adolescente , Adulto , Niño , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
The use of balloon-expandable stents provides an effective alternative therapy in patients with stenotic lesions in congenital heart disease. Stents implantation has served to improve the results and to reduce complications of balloon angioplasty for coarctation and recoarctation of the aorta. AIM: We report our results after primary stents implantation for coarctation and recoarctation of the aorta. PATIENTS AND METHODS: Balloon-expandable stents were implanted in 14 patients (mean age 20 +/- 12 years) with coarctation of the aorta (11 native and 3 postoperative); 2 patients had associated malformations. The morphology varied: 10 resembled a located-diaphragm (one of them with moderate arch hypoplasia); 2 had distorted coarctation and 2 had a complete aortal obstruction. Five patients were hypertensive and 1 had cardiogenic shock and severe arrhythmias which did not respond to intensive medical therapy. In all cases 14 Palmaz stents (7 P308 and 7 P4014) were implanted with the primary technique through a Mullin's sheath. The balloon-to-descending aorta diameter ratio, measured at the level of the diaphragm, was 1. A special technique was carried out in the 2 cases with complete aortal obstruction. RESULTS: The procedure was effective in all 14 cases. The coarctation diameter increased from 4 +/- 2 to 15 +/- 2 mm (p < 0.0001) and transcoarctation systolic pressure gradient decreased from 43 +/- 19 to 2 +/- 2 mmHg (p < 0.0001). The ratio of the coarctation to descending aorta diameter measured at the level of the diaphragma increased from 0.3 +/- 0.1 to 0.95 +/- 0.05 (p < 0.001). At 19 +/- 8 months follow up, all patients showed sustained clinical improvement. The patient with complete aortal obstruction experienced a dramatic improvement, but she died from a sudden cardiac event 22 months after the procedure. At angiographic follow up in 7 patients, 1 year after implantation, no recoarctation was observed with secondary vessels patent, and absence of restenosis. CONCLUSIONS: a) Percutaneous endovascular stents implantation in coarctation and recoarctation of the aorta may become an effective treatment modality in the older child, adolescent and adults; b) stents are particulary attractive in those patients with a more complex anatomy and higher surgical risk; c) primary stenting is expected to have a lower rate of complications, and d) we describe a special technique with a right femoral-left humeral arterial circuit that is successfully applied to patients with complete aortal obstruction.
RESUMEN
We report the case of a 6-year-old girl with mitral atresia, hypoplastic left ventricle with a large right ventricle from which the main vases flow with a normal relationship and pulmonary obstruction, in which a modified fenestrated Fontan procedure with Gore-Tex baffle was performed. In the course of the treatment she developed cyanosis and a significant desaturation related to the presence and development of a levoatrial cardinal vein which was treated effectively using Gianturco coils with a good latter evolution. We discuss the possibilities of right-to-left shunting post Fontan procedure, percutaneous treatment as an alternative to surgery, the technique and angiographic characteristics of this case.