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Se reporta un caso excepcional de tumor de Krukenberg ovárico bilateral asociado a teratoma maduro encontrado en una mujer de 54 años. La ecografía mostró al lado derecho tumor ovárico sólido de 55 mm y al lado izquierdo tumor quístico de 125 mm. Se realizó histerectomía total, salpingooforectomía bilateral, resección del epiplón mayor y muestras peritoneales. Al tercer día postcirugía, la paciente presentó signos de tromboembolismo pulmonar masivo y aunque recibió terapia anticoagulante falleció al quinto día postoperatorio. El estudio histológico mostró infiltración masiva de carcinoma de células en anillo positivas para citoqueratina en ambos ovarios. El ovario derecho mostró la forma sólida clásica del tumor de Krukenberg mientras que el ovario izquierdo correspondió a un quiste dermoide con infiltración tumoral de carcinoma de células en anillo en la pared.

An exceptional case of bilateral Krukenberg tumor of the ovary associated with mature teratoma presented in a 54 years old patient is reported. The ultrasound showed a 55 mm solid right ovarian tumor and a 125 mm left cystic ovarian tumor. Hysterectomy and bilateral salpingoophorectomy was performed including omental resection and peritoneal biopsies. Massive pulmonary embolism was detected in the third day after the surgery. Even anticoagulant therapy was established the patient died in the fifth postoperative day. The histological study revealed massive infiltration of signet ring cell carcinoma with positive expression for cytokeratin in both ovaries. The right ovary showed the classical solid form of the tumor. The left ovary was a dermoid cyst with signet ring cell carcinoma infiltrating the cystic wall.

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RESUMO

Persistent left superior vena cava is the most common venous congenital malformation and is usually asymptomatic. Its presence could increase the difficulty for transvenous lead implantation. We report a 71-year-old woman with an idiopathic dilated cardiomyopathy, atrial fibrillation and heart failure that required biventricular resynchronization therapy. During the placement of the device a persistent left superior vena cava was detected. The device was placed without problems and the patient had a satisfactory postoperative evolution.

Assuntos

RESUMO

Persistent left superior vena cava is the most common venous congenital malformation and is usually asymptomatic. Its presence could increase the difficulty for transvenous lead implantation. We report a 71-year-old woman with an idiopathic dilated cardiomyopathy, atrial fibrillation and heart failure that required biventri-cular resynchronization therapy. During the placement of the device a persistent left superior vena cava was detected. The device was placed without problems and the patient had a satisfactory postoperative evolution.

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RESUMO

We report a 26year old patient who had a single chamber pacemaker implantation one year before. During a routine pre-operative evaluation, pacemaker dysfunction was demonstrated due to sensing and pacing failure, associated to left pectoral muscle rhythmic contraction. Chest X-ray confirmed Twiddler syndrome, in which twisting or rotation of the device inside the pocket results in lead dislodgement and device malfunction.

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Este trabajo intenta comparar dos hipótesis dinámicas clínicas: la teoría de la “sobreadaptación” de Liberman y el “complejo de la madre muerta” de André Green, en términos de procesos que remiten a experiencias vinculares tempranas fallidas que inciden en fracasos (parciales) de la capacidad de simbolización. Se revisan algunos conceptos de Winnicott y Bion acerca de la construcción del aparato psíquico, el desarrollo del “self ambiental sobreadaptado” en los planteamientos de Liberman y la identificación con aspectos muertos de la madre en la teoría de Green, concluyendo que se trata de experiencias traumáticas encapsuladas que pueden “re-presentarse” en la relación transferencial para ser analizadas

This paper tries to compare two clinical dynamic hipothesis: Liberman´s theory about "over-adaptation" and André Green´s idea of the "dead mother complex". Both are processes linked to failure in early bonding experiences which affect (partially) symbolic ability. Some concepts of Winnicott and Bion are reviewed about psychic construction, environmental over-adapted self, who are beneath Liberman´s exposition. Also states that the identification with the dead mother aspects is an important issue in the development. Concluding that there is a failure in the object task that disturb the psychic constitution which are settled as encapsulated traumatic experiences that could be "re-presented" in the transference relationship to have the opportunity of being analyzed

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BACKGROUND: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. AIM: To evaluate CPV in patients with AF submitted to valvular surgery. PATIENTS AND METHODS: Twenty one patients had simultaneous valvular surgery and CPV, 81 % of them had permanent AF for an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7 patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60 degrees C for 2 minutes with two 15 mm cryoprobes applied simultaneously. RESULTS: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8% (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50% of patients were in normal sinus rhythm and 25% persisted in AF. The remaining patients were in some type of regular rhythm. CONCLUSIONS: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50% of the cases, with low morbidity and mortality and little increment in surgical time.

Assuntos

RESUMO

We report a 59 year-old woman who had recurrent episodes of paroxystic supraventricular tachycardia despite pharmacologic therapy. A previous electrophysiological study (EPS) was done two years earlier without induction of any sustained arrhythmia. A new EPS was performed, during which atrial and ventricular programmed stimulation failed to induce tachycardia, and only by fast ventricular stimulation during intravenous isoproterenol infusion, a typical atrio ventricular nodal reentrant tachycardia (AVNRT) was induced. We successfully ablated the slow nodal pathway. After ablation the tachycardia was not inducible. We comment the occasional difficulties to induce AVNRT and the importance of a complete induction protocol to avoid false negative studies during the EPS.

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El tratamiento de la rinitis alérgica (RA) en la paciente embarazada se ve obstaculizado por el temor que el especialista experimenta al intentar utilizar medicamentos que podrían provocar problemas en el desarrollo del feto. Este dilema es especialmente acentuado cuando la embarazada está en sus primeros meses de embarazo. Sin embargo, la persistencia de síntomas y las molestias que la rinitis alérgica le ocasiona a la paciente coloca al especialista en una disyuntiva importante: cómo tratar a la enferma sin provocar daños en el niño en gestación. La FDA ha clasificado los medicamentos que en estos casos pueden utilizarse y el metaanálisis de estudios realizados en embarazadas avala la prescripción de los fármacos que aquí se aconsejan. Es factible, además, realizar algunos procedimientos quirúrgicos durante el embarazo sin que ello involucre riesgo en la paciente ni en el feto.

Assuntos

RESUMO

Background: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. Aim: To evaluate CPV in patients with AF submitted to valvular surgery. Patients and Methods: Twenty one patients had simultaneous valvular surgery and CPV, 81 percent of them had permanent AFfor an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60°C for 2 minutes with two 15 mm cryoprobes applied simultaneously. Results: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8 percent (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50 percent of patients were in normal sinus rhythm and 25 percent persisted in AF. The remaining patients were in some type of regular rhythm. Conclusions: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50 percent of the cases, with low morbidity and mortality and little increment in surgical time.

Assuntos

RESUMO

We report a 59 year-old woman who had recurrent episodes of paroxystic supraventricular tachycardia despite pharmacologic therapy. A previous electrophysiological study (EPS) was done two years earlier without induction of any sustained arrhythmia. A new EPS was performed, during which atrial and ventricular programmed stimulation failed to induce tachycardia, and only by fast ventricular stimulation during intravenous isoproterenol infusion, a typical atrio ventricular nodal reentrant tachycardia (AVNRT) was induced. We successfully ablated the slow nodal pathway. After ablation the tachycardia was not inducible. We comment the occasional difficulties to induce AVNRT and the importance of a complete induction protocol to avoid false negative studies during the EPS.

Assuntos

RESUMO

Cardiac resynchronization therapy is a non-pharmacological treatment for patients with dilated cardiomyophaty and congestive heart failure. The success of this therapy depends of permanent biventricular stimulation. We report an 84 year-old man, with intermittent loss of biventricular pacemaker stimulation despite having adequate sensing and stimulation thresholds in the right atrium and both ventricles. The problem was solved after correcting some programming parameters.

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RESUMO

Background: Electrode lead design and materials influence their performance, stability and manipulation characteristics. In our laboratory, we use straight intracardiac, active fixation, steroid eluting leads. These features are shared by three brands of pacemarker distributors. Aim: To compare the short term results of three brands of leads used in our laboratory in patients requiring the implant of a pacemarker of cardioverter. Material and methods: One hundred and four patients (mean age 70 years, 59 males) subjected to a pacemarker or cardioverter implant were studied and followed during the first three months post implant. In these patients, 49 Guidant Flextend® 4087 or 4088, 27 Saint Jude Tendril® 1488T and 10 Medtronic Capsurefix® 5076 leads were implanted in the right atrium and 60 Guidant Flextend® 4087 or 4088, 29 Saint Jude Tendril® 1488T and 19 Medtronic Capsurefix® 5076 leads were implanted in the right ventricle. Results: Implant parameters were adequate for all leads. A sub-acute rise in ventricular stimulation threshold was detected in one Flextrend® lead. Three atrial leads (two Flextend® and one Capsurefix®) and one Capsurefix® ventricular lead experienced an acute displacement. One patient with a Flextend® lead, had a cardiac tamponade caused by an atrial perforation. Conclusions: The three brands of leads tested can be successfully implanted with comparable parameters and without differences in the evolution of patients during the first three months.

Assuntos

RESUMO

Cardiac resynchronization therapy is a non-pharmacological treatment for patients with dilated cardiomyophaty and congestive heart failure. The success of this therapy depends of permanent biventricular stimulation. We report an 84 year-old man, with intermittent loss of biventricular pacemaker stimulation despite having adequate sensing and stimulation thresholds in the right atrium and both ventricles. The problem was solved after correcting some programming parameters.

Assuntos

RESUMO

The prevalence of congestive heart failure has increased in the world. Despite advances in pharmacological treatment, some patients have progression of the disease and deterioration of their functional class. In this group of patients cardiac resynchronization therapy has been accepted as a treatment option. However, some patients are non-responders to cardiac resynchronization, and others who respond favorably, will experience reappearance of their symptoms. For these patients, multisite stimulation with the implant of a second electrode in the right ventricle has been published as a new option. We report a 76 year-old woman with a dilated cardiomyopathy, who was treated with resynchronization therapy with good clinical response during two years, but symptoms of congestive heart failure reappeared and her functional class deteriorated to NYHA class IV. She was successfully treated with right ventricular multisite stimulation, with a reduction of symptoms that has lasted during the two months of follow up after the procedure.

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RESUMO

Background: Since February 2002, Flextend® electrode catheters are used at the Cardiovascular Unit of the Catholic University Clinical Hospital. These transvenous catheters have an IS-1 connector, silicone coating, active fixation and retractile helix with dexamethasone acetate. Aim: To report early and one year results using Flextend® catheters. Material and methods: Retrospective analysis of all patients that received an implant of a Flextend® catheter in the Unit. Results: Forty one Flextend® catheters were implanted in 24 patients, without acute displacement or clinical pericarditis. In 18 electrode catheters located in the right atrium the mean values for p wave, stimulation threshold and impedance at the moment of placement, were 2.9±1.4 mV, 0.8±0.4 V and 522±86 Ohms, respectively. The figures 24 hours after placement were 3.6±2.1 mV, 0.8±0.3 V and 612±69 Ohms, respectively. In 23 electrode catheters in the right ventricle, mean values at the moment of placement for R wave, stimulation threshold and impedance were 11.3±3.6 mV, 0.8±0.2 V and 756±108 Ohms, respectively. The figures 24 hours after placement were 3.6±2.1 mV, 0.8±0.3 V and 612±69 Ohms, respectively. In one patient, the stimulation threshold increased two months after placement and required a new intervention. Conclusions: Flextend® catheters ca be placed successfully with a low rate of complications and stable function parameters on follow up.

Assuntos

RESUMO

Persistent left superior vena cava and absent right superior vena cava is an uncommon anatomical association. This is a challenging situation for permanent pacemaker implantation. We report three patients with this anomaly and a permanent pacemaker successfully implanted through the left superior vena cava and coronary sinus, without acute or chronic complications.

Assuntos

RESUMO

The prevalence of congestive heart failure has increased in the world. Despite advances in pharmacological treatment, some patients have progression of the disease and deterioration of their functional class. In this group of patients cardiac resynchronization therapy has been accepted as a treatment option. However, some patients are non-responders to cardiac resynchronization, and others who respond favorably, will experience reappearance of their symptoms. For these patients, multisite stimulation with the implant of a second electrode in the right ventricle has been published as a new option. We report a 76 year-old woman with a dilated cardiomyopathy, who was treated with resynchronization therapy with good clinical response during two years, but symptoms of congestive heart failure reappeared and her functional class deteriorated to NYHA class IV. She was successfully treated with right ventricular multisite stimulation, with a reduction of symptoms that has lasted during the two months of follow up after the procedure.

Assuntos

RESUMO

BACKGROUND: Electrode lead design and materials influence their performance, stability and manipulation characteristics. In our laboratory, we use straight intracardiac, active fixation, steroid eluting leads. These features are shared by three brands of pacemaker distributors. AIM: To compare the short term results of three brands of leads used in our laboratory in patients requiring the implant of a pacemaker or cardioverter. MATERIAL AND METHODS: One hundred and four patients (mean age 70 years, 59 males) subjected to a pacemaker or cardioverter implant were studied and followed during the first three months post implant. In these patients, 49 Guidant Flextend 4087 or 4088, 27 Saint Jude Tendril 1488T and 10 Medtronic Capsurefix 5076 leads were implanted in the right atrium and 60 Guidant Flextend 4087 or 4088, 29 Saint Jude Tendril 1488T and 19 Medtronic Capsurefix 5076 leads were implanted in the right ventricle. RESULTS: Implant parameters were adequate for all leads. A sub-acute rise in ventricular stimulation threshold was detected in one Flextrend lead. Three atrial leads (two Flextend and one Capsurefix) and one Capsurefix ventricular lead experienced an acute displacement. One patient with a Flextend lead, had a cardiac tamponade caused by an atrial perforation. CONCLUSIONS: The three brands of leads tested can be successfully implanted with comparable parameters and without differences in the evolution of patients during the first three months.

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RESUMO

Background: The costs of medical care increase along with technological advances. Therefore, highly complex and expensive procedures should be performed in a limited number of institutions. Aim: To report the initial experience on electrophysiological studies performed to beneficiaries of a public health insurance system in Chile (FONASA). Material and methods: An agreement was reached between the Electrophysiology Unit of the Clinical Hospital of the Catholic University and FONASA, to perform electrophysiological studies at a minimal cost, that only considered disposable materials and hospital stay. Thirty patients with supraventricular arrhythmias or ventricular arrhythmias without an associated cardiopathy, were attended using this agreement at the unit. Results: In all treated patients, arrhythmias disappeared. Costs remained within the assigned budget, excepting occasional complementary tests. Conclusions: This pioneering experience demonstrated that it is possible that public health insurance systems can buy complex and expensive procedures to private hospitals.

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