Biomedical subjects
Publications and source records attributed to E Esplugas.
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Complete heart block (CHB) is a rare complication of systemic lupus erythematosus (SLE), mainly seen during an acute flare-up of the disease or after high-dose long-term treatment with antimalarial drugs, although anti-Ro and anti-RNP antibodies have also been implied by some authors. A 40-y-old woman developed CHB in the context of an acute flare-up of SLE, first diagnosed three years ago, having recently commenced hydroxychloroquine (HCQ) treatment. Anti-Ro and anti-RNP antibodies were also positive. No features of myocarditis were found. A temporary pacemaker was required and complete resolution was achieved on steroid therapy with withdrawal of antimalarial therapy. The characteristics of previous cases are well publicised and discussion focuses on the possible aetiology and pathogenesis of the present case.
INTRODUCTION AND AIMS: In patients with coronary risk factors the presence of endothelial dysfunction in epicardial arteries has been documented. The purpose of this study was to determine whether endothelial dysfunction, documented hypercholesterolemic patients and angiographically normal coronary arteries, improves by reduction and normalization of lipid levels. PATIENTS AND METHOD: In 10 patients with hypercholesterolemia and normal coronary angiography, the endothelium-dependent coronary vasomotion was studied by intracoronary infusion of acetylcholine into the left anterior descending coronary artery. Vasomotion changes in response to acetylcholine were analyzed by quantitative angiography. Five patients without coronary risk factors and normal coronary arteries formed the control group. Patients with hypercholesterolemia were treated with lipid-lowering therapy (diet and lovastatin) and endothelial function was reevaluated after 24 +/- 4 months. RESULTS: In the initial study, hypercholesterolemic patients compared with the control group showed a vasoconstrictor response to serial doses of acetylcholine(10(-6) M, 10(-5) M, 10(-4)M) indicative of endothelial dysfunction (study group: -0.3 +/- 10%, -6 +/- 4%, -18 +/- 10% vs control group: -0.6 +/- 6%, -2 +/- 6%, 3+/-6%; p < 0.01 to 10(-4) M acetylcholine dose. During follow-up hypercholesterolemic patients who a significant reduction in total cholesterol levels and LDL. Compared to first study, at follow-up, there was an improvement in the response to acetylcholine (-0.4 +/- 4%, -3 +/- 6%, -3 +/- 10%; p<0.001 vs basal values at 10(-4) M acetylcholine concentration). Reduction in total cholesterol during follow-up was related to the improvement in the vasoconstrictor response to acetylcholine (r=0.53; p< 0.05). CONCLUSION: In patients with hypercholesterolemia and angiographycally normal coronary arteries with documented endothelial dysfunction, the reduction and normalization of lipid levels during follow-up may improve endothelium-dependent coronary vasomotion.
Stent restenosis constitutes a therapeutic challenge affecting an increasing number of patients. Conventional angioplasty and debulking techniques are currently used in these patients. However, the potential role of a second stent implantation in this setting (stenting the stent) remains unknown. Therefore, 65 consecutive patients (12 women, aged 62 +/- 11 years) undergoing stent implantation (42 elective and 23 unplanned) for the treatment of in-stent restenosis (diffuse [> 10 mm] in 39 [60%]) were studied. Angiographic success was obtained in all patients. Three patients developed hospital complications: 1 died from refractory heart failure and 2 suffered non-Q-wave myocardial infarctions. During follow-up (mean 17 +/- 11 months) 1 patient died (noncardiac cause) and only 9 (14%) required target vessel revascularization. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) at 1 year was 84%. Using Cox analysis, patients with unstable symptoms, a short time to stent restenosis, nonelective stenting, and B2-C lesions tended to have poorer prognosis. After adjustment, nonelective stenting was associated (adjusted RR 2.9, 95% confidence interval [CI] 0.82 to 10.3, p = 0.09) with an adverse clinical outcome. On quantitative angiography (core lab) restenosis was found in 13 of 43 patients (30%) (75% of those eligible). Logistic regression analysis identify restenosis length (adjusted RR 1.43, 95% CI 1.04 to 2.14, p = 0.04), and time to restenosis (adjusted RR 0.67, 95% CI 0.47 to 0.94, p = 0.01) as the only independent predictors of recurrent restenosis. Thus, repeat coronary stenting is a safe and efficacious strategy for the treatment of patients with in-stent restenosis. Both elective and nonelective stenting provide excellent initial results. The long-term clinical and angiographic outcome of these patients is also favorable.
BACKGROUND: The potential merits and disadvantages of the use of ionic or nonionic contrast media in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) have been the subjects of controversy. The present study was designed to evaluate the possible influence of both types of contrast media on major adverse cardiac events (MACE) in patients undergoing PTCA. METHODS AND RESULTS: In a randomized, parallel-group, double-blind study, 1411 patients received either iodixanol (a nonionic, iso-osmolar contrast medium) or ioxaglate (an ionic, low-osmolar contrast medium) during PTCA. A standardized anticoagulation regimen was followed. Patients were monitored in the hospital for 2 days and followed-up at 1 month. The primary end point, a composite of MACE (death, stroke, myocardial infarction, coronary artery bypass grafting, and re-PTCA) after 2 days, occurred in 4.3% of the total population, with no statistically significant difference between groups (iodixanol, 4.7%; ioxaglate, 3.9%; P=0.45). Further, between 2-day and 1-month follow-ups, no significant difference (P=0.27) existed between the groups in the rates of MACE. Hypersensitivity reactions (P=0.007) and adverse drug reactions (P=0.002) were significantly less frequent in the iodixanol group. The only significant predicting factors for the occurrence of MACE were dissection/abrupt closure and country. CONCLUSIONS: No significant differences were observed between the iodixanol and ioxaglate groups with regard to MACE, although hypersensitivity and adverse drug reactions were significantly less frequent in patients who received iodixanol.
Interventional cardiology has had an extraordinary expansion in last years. This clinical guideline is a review of the scientific evidence of the techniques in relation to clinical and anatomic findings. The review includes: 1. Coronary arteriography. 2. Coronary balloon angioplasty. 3. Coronary stents. 4. Other techniques: directional atherectomy, rotational atherectomy, transluminal extraction atherectomy, cutting balloon, laser angioplasty and transmyocardial laser and endovascular radiotherapy. 5. Platelet glycoprotein IIb/IIIa inhibitors. 6. New diagnostic techniques: intravascular ultrasound, coronary angioscopy, Doppler and pressure wire. For the recommendations we have used the classification system: class I, IIa, IIb, III like in the guidelines of the American College of Cardiology and the American Heart Association.
Giant pseudoaneurysms of coronary arteries in patients with Behçet's disease is a uncommon finding. It has been described exceptionally in the literature. We present a case of giant pseudoaneurysm of the left anterior descending coronary artery with obstruction of the right ventricular outflow in a patient with Behçet's disease. He improved after surgical resection and steroid treatment.
In our environment, the use of Fab antibodies for digoxin intoxication is often difficult due to the low availability of this drug in most centers. We present a case of massive digoxin intoxication that was successfully managed with the classic treatment. Later, we discuss the need to individualize the management of this kind of intoxications in order to reduce, when possible, sanitary costs.
BACKGROUND: Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS: The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS: At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS: Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.
STUDY OBJECTIVES: This study was performed to assess the changes in pulmonary function after a successful percutaneous balloon mitral valvotomy (PBMV) in 23 consecutive patients with symptomatic mitral stenosis. METHODS AND RESULTS: Lung function preprocedure and postprocedure were evaluated by spirometric flow, static pulmonary volumes, and diffusion capacity of the lung for carbon monoxide (DLCO). At baseline, a reduction in small airways flow (maximal expiratory flow at 50% of vital capacity, 70 +/- 29% of predicted value; maximal expiratory flow at 25% of vital capacity, 55 +/- 26% of predicted value) and an increase in DLCO (118 +/- 29%) and Krough Index (KCO; 123 +/- 29% of predicted value) were observed. PBMV caused an improvement in hemodynamic parameters with an increase in mitral valve area (from 1.0 +/- 0.3 to 1.9 +/- 0.5 cm(2); p < 0.001) and a decrease in left atrial pressure (from 17 +/- 3 to 12 +/- 5 mm Hg; p < 0.001). These changes were associated with a significant increase in FVC (from 2.8 +/- 0.84 to 2.9 +/- 0.80 L; p < 0.05) and in FEV(1) (from 2.2 +/- 0.72 to 2.3 +/- 0.68 L; p < 0.05). A decrease in DLCO was observed after PBMV (from 26.7 +/- 7 to 22.5 +/- 5.4 mL/min/mm Hg; p < 0.001; and KCO, from 6.2 +/- 1.4 to 5.2 +/- 1.2 mL/min/mm Hg/L; p < 0.001). No significant changes in small airways flow were detected, suggesting only a partial improvement in pulmonary congestion. CONCLUSION: We conclude that the initial impairment of lung function in patients with symptomatic mitral stenosis is only partially ameliorated by PBMV.
The authors describe a case reported in a young female with antecedents of aortic pathology and renovascular hypertension submitted to renal artery surgery admitted to emergency with an extensive acute myocardial infarction, treated with thrombolysis. After coronariography we identify, as etiological factor, a spontaneous coronary dissection involving the descending anterior coronary artery and circumflex coronary artery with no affect on the left main coronary artery. About this case, the authors make a brief review of the literature emphasizing the therapeutic options.
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Acute hepatitis for intravenous amiodarone is an uncommon problem with scarce appearances in medical literature. Sometimes, it has postulated that the vehicle of the intravenous preparation and not the active principle is the possible cause of this complication. We report a patient with fulminating hepatitis and severe encephalopathy following the administration of intravenous amiodarone. We present also the clinical evolution of the patient after reintroduction of oral amiodarone. In the end, we make a review of the associated literature with our case.
Functional mitral regurgitation is frequently observed in the setting of left ventricular dyfunction. This finding is a marker of poor outcome in patients with either ischemic or dilated cardiomyopathy. The mechanism accounting for this phenomenon is an altered balance of tethering versus coapting forces acting on the mitral valves in the failing heart. Tethering forces represent an anomalous tension on the mitral valves due to displacement of mitral valve attachments secondary to increased left ventricular chamber sphericity associated with systolic ventricular dysfunction. On the other hand, coapting forces are weak and unable to counteract the abnormal tension acting on the mitral valve, which restricts closure and leads to regurgitation. Vasodilators and inotropic drugs are effective in the management of functional mitral regurgitation. Although partial left ventriculectomy or Batista's procedure is still investigational, this new technique seems to provide an optimal control of functional mitral regurgitation and improve functional capacity and survival of some patients with heart failure.
Myocardial infarction is an uncommon complication of electroconvulsive therapy. Because of this, in spite of the existence in psychiatric literature of some studies about this question, the knowledge in this regard by most cardiologists is scarce. We present a patient with an acute myocardial infarction after the application of a electroconvulsive therapy. In the end, we accomplish review of the literature in relation to incidence, physiology, prevention and indication or not of fibrinolytic drugs in acute myocardial infarction after electroconvulsive therapy.