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ABSTRACT: To assess the clinical outcome of coronary stenting in small vessels (< 3 mm), using high pressure balloon inflation and antithrombotic therapy.
Vessel size was evaluated as < or >= 3 mm at the time of procedure and measured at a level of maximum diameter. We studied 234 consecutive patients with placement of 300 stents in 279 lesions, comprising 84 stents implanted in 79 lesions located at small vessels (< 3 mm). The standard technique included high pressure balloon inflation (15.8 +/- 2.2 atm) and post-stenting therapy with ticlopidine and aspirin for one month. Mean clinical follow-up was 17.6 +/- 10 months.
Procedural success without in-hospital major events was similar between small and large vessels (93.7 in vessels of < 3 mm vs 93.5% in vessels of >= 3 mm; p = NS). Three small vessels presented subacute stent thrombosis, whereas no thrombotic occlusion occurred in large vessels (3.8 vs 0%; p = 0.006). At two years, small vessels had a lower target lesion revascularization free survival (73.6 vs 90.3%; p < 0.001). After adjustment for variables previously described as predictors of stent restenosis, in multivariate analysis, a small vessel of < 3 mm was an independent predictor of target lesion revascularization (p = 0.001). Although patients with stenting in small vessels did not differ significantly in terms of any cause death (4.6 vs 3.8%; p = 0.7) nor acute myocardial infarction (2.9 vs 1.1%; p = 0.3), event-free survival was significantly lower after two years (69.1 vs 86.6%; p < 0.001).
As compared to large vessels, coronary stenting in small vessels was performed with similar rates of initial success, however they had a significantly worse clinical long-term outcome in terms of subacute stent thrombosis and target lesion revascularization at follow-up.
Revista Espa de Cardiologia 09/2000; 53(8):1040-6. · 2.53 Impact Factor
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ABSTRACT: Intraoperatory awakening or awareness can be defined as recovering of conscience during general anesthesia. We report such a case happened in a 11 year-old boy during a hypospadias repair. After anesthetic education he related intraoperatory conscience without pain, anxiety, displeasing symptoms or long-term psychoconductal distress. We remark fisiopathology, diagnostic and preventive aspects of this rare event in pediatric surgery.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 05/2000; 13(2):81-3.
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ABSTRACT: Median raphe cysts of the perineum are uncommon congenital lesions. Congenital lesions rarely encountered in daily clinical practice. Their diagnosis in childhood is particularly rare. We report two children with these cysts requiring surgical removal. We review the embryological, diagnostic and therapeutic aspects of these cysts, which could be of interest to pediatricians and pediatric surgeons when faced with this pathology in children.
Anales espanoles de pediatria 05/2000; 52(4):395-7.
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ABSTRACT: In patients with previous myocardial infarction (MI), depressed heart rate variability (HRV) may reflect a reduction in vagal activity and lead to cardiac electrical instability. Interventions designed to increase HRV may be of clinical interest. Data on the effects of calcium antagonists on HRV in post-MI patients are very limited. The aim of our study was to assess the effects of verapamil on HRV and on the sympathovagal balance after MI. Fifty consecutive patients with a first MI, stable sinus rhythm, and left ventricular ejection fraction >0.40 were studied. Each patient underwent two 24-hour Holter recordings, 1 at baseline and another after 4 days of treatment with verapamil retard (180 mg 2 times daily). Time and frequency domain parameters of HRV were analyzed. All time domain measurements increased significantly after verapamil: the standard deviation of all NN intervals (SDNN) from 87.1 +/- 31.4 to 98.1 +/- 30.3 ms (p <0.05) and the log-transformed percentage of pairs of adjacent NN intervals that differ >50 ms (pNN50) from 0.57 +/- 0.42 to 0.76 +/- 0.45 (p <0.01). The standard deviation of the averages of RR interevals (SDANN) (75.9 +/- 30.1 vs 86.3 +/- 29.4 ms, p <0.05), root-mean-square of successive differences between RR intervals (rMSSD) (23.0 +/- 11.7 and 28.1 +/- 13.1 ms, p <0.01), and the triangular HRV index (28.3 +/- 9.6 vs 23.4 +/- 8.6, p <0.001) also increased. A significant inverse correlation was found between improvement in HRV indexes induced by verapamil and baseline values. Spectral analysis showed a significant increase in high-frequency power of 58.5% without changes in low and very low components. With normalized units, significant reductions in low-frequency power and low- to high-frequency ratio were observed. Diabetic patients did not show any significant changes in HRV on administration of verapamil. These findings indicate that verapamil, administered during the subacute phase of MI, improves both global and short-period indexes of HRV and induces a shift in the sympathetic-parasympathetic interaction toward vagal predominance. This effect may contribute to an explanation of the beneficial effects of verapamil that have been reported in post-MI patients.
The American Journal of Cardiology 06/1998; 81(9):1085-9. · 3.37 Impact Factor
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ABSTRACT: We report the case of a 64-year-old patient admitted for repetitive syncope as an isolated clinical manifestation probably due to coronary artery spasm. The patient had no history of previous cardiac disease, and was studied because of two nonspecific syncopes. Long-term electrocardiographic monitoring showed many episodes of transient ST segment elevation, associated with premature ventricular beats and runs of ventricular tachycardia. Coronary angiography during ergonovine infusion was performed to confirm the diagnosis. We discuss the incidence of coronary spasm provoking syncope and the need to establish a correct diagnosis in order to administer an effective therapy to the patient.
Revista Espa de Cardiologia 11/1997; 50(10):733-7. · 2.53 Impact Factor
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ABSTRACT: Conventional exercise testing before hospital discharge is the most useful procedure in order to estimate postinfarction prognosis and in detecting multivessel coronary disease which is associated with a poor long-term prognosis. There are no bibliographic reports about it in younger myocardial infarction survivors. The aim of the study was to evaluate sensitivity, specificity and predictive value of symptoms limited maximal exercise testing for multivessel disease diagnosis in young patients after myocardial infarction.
Myocardial infarction survivors until the age of 40 performed symptoms limited maximal exercise testing and had a coronary arteriography before hospital discharge.
A total of 100 consecutive patients were included, although in only 83 of them exercise tests and coronariographic studies were done. In this group, multivessel disease was confirmed in 27 patients (15 with positive tests and 12 with normal exercise testing). In the remaining 56 young adults without multivessel involvement, positive tests were only observed in 15 patients and normal tests in 45. Thus, a sensitivity of 56%, specificity of 73%, positive predictive value of 50% and negative predictive value of 77% were found. When patients showed high risk exercise test criteria, the exercise test positive predictive value increased to 80%.
Due to the lower sensitivity of this test in young myocardial infarction survivors for detecting multivessel artery disease, we remark on the need for predischarge complementary tests such as isotopic, stress echocardiography or coronariography testing.
Revista Espa de Cardiologia 07/1997; 50(6):416-20. · 2.53 Impact Factor
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ABSTRACT: Regarding restenotic lesions, the data suggest that stent implantation decrease the number of cardiac events including the restenosis rate. The higher number of acute cardiac events are related to stent thrombosis, and they are markedly reduced by the new techniques of antiagregation and implantation. The restenosis rate post-stent implantation does not bear relation to the number of previous dilations as it does with conventional angioplasty. Regarding vein grafts, the implantation of different types of stents has a high percentage of success and low rate of acute complications. The longterm survival of these patients is related more to the progression of the coronary arteriosclerosis and tend to worsen with time. Although the data on restenosis are better than with conventional angioplasty, we need to wait for the definitive results after the final conclusions of the randomized trial SAVED.
Revista Espa de Cardiologia 02/1997; 50 Suppl 2:10-20. · 2.53 Impact Factor
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ABSTRACT: Although rare, anomalous coronary arteries are associated with myocardial ischemia and sudden death. Identification is made by angiography but its true course is difficult to determine even with this invasive procedure.
The purpose of this study is to determine the role of transesophageal echocardiography (TEE), Doppler and color flow Doppler, in identifying the origin and course of anomalous coronary arteries.
Six patients with angiographically confirmed anomalous coronary arteries were studied by TEE, Doppler and color flow Doppler.
The abnormal origin was confirmed in all six patients. In three, the left main originated from the right sinus of Valsalva. In one the right coronary artery from the left sinus of Valsalva. One was a single right coronary artery from the right sinus of Valsalva, and one, had a fistula between the coronary artery and the right ventricle. In four, the TEE was able to demonstrate clearly the course in relation to the great vessels, two were interarterial and one posterior. Color flow Doppler was obtained in four patients. In one patient, there was increase in diastolic flow velocity due to proximal coronary obstruction. One had increase of the systolic flow velocity.
TEE is useful test for diagnosing the origin of anomalous coronary arteries and confirming its course in relation to the great vessels. Doppler flow Doppler is useful in localization the vessel.
Revista Espa de Cardiologia 10/1996; 49(9):657-62. · 2.53 Impact Factor
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ABSTRACT: Coronary stents have proved their efficacy in bail-out situations and restenosis. Nevertheless, the high incidence of subacute thrombosis and vascular and bleeding complications limits its use.
To evaluate the clinical complications during the first month of three different types of stents, implanted with high pressure, without ultrasound guidance or anticoagulation.
All stents were implanted in arteries of 3 mm or more. After implantation, all stents were dilated between 15-17 atmospheres, aiming to a residual stenosis lower than 10%. After implantation, all patients received aspirin indefinitely and ticlopidine 250 mg twice daily for one month. The initial success, the ischemic complications (death, myocardial infarction and emergency surgery), acute and subacute thrombosis and vascular and hemorrhagic complications were evaluated. The evaluation was done following the procedure, prior to discharge from the hospital and at 1 month follow-up.
In 49 patients, 51 stents were implanted. 70% had unstable angina. In one case the stent was implanted after primary PTCA. In 17.6%, the stent was implanted in a bail-out situation. Of the 51 stents, 32 were Palmaz-Schatz, 12 Wiktor and 7 Gianturco-Roubin. The initial success was 100%. There were no deaths, AMI, nor emergency surgeries in the first month. There was no case of acute or subacute thrombosis. There were 2 minor complications; one vascular: a pseudoaneurysm, and another hemorrhagic: an inguinal hematoma. Neither case needed surgery nor blood transfusion. All patients were discharged within 48 hours.
Implantation of stents with high pressures, in spite of not using guidance ultrasound nor anticoagulation, is safe and effective, with a clear decrease in vascular complications, and without an increase in the incidence of acute or subacute thrombosis.
Revista Espa de Cardiologia 07/1996; 49(6):432-8. · 2.53 Impact Factor
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ABSTRACT: We present the case of an old patient with coronary artery disease and two previous myocardial infarctions, admitted to the hospital by syncopal episodes, in which the coronariographic study showed the ectopic origin of the left main coronary artery in the right sinus of Valsalva with anomalous course between the aortic and pulmonary arteries. In this case the initial coronariographic diagnosis and the therapeutical attitude (initially aggressive only in cases of interarterial course) was confirmed by mean of transesophageal echocardiography, showing a better topographical definition of the ectopic vessel aberrant course, although due to the high degree of left ventricular disfunction and the diffuse disease of distal vessels in this patient, CABG surgery was avoided. The angiographic feature is described and the transesophageal approach is remarked as a complementary diagnostic tool in the correct definition of the anomalous course.
Revista Espa de Cardiologia 04/1995; 48(3):208-10. · 2.53 Impact Factor
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ABSTRACT: Atrial pacing has been proposed as an alternative method to the isotonic exercise, to induce ischemia, and, joined to two-dimensional echocardiography, as one of the main modalities in stress echo. In order to analyse its applicability and diagnostic value in assessing coronary artery disease this study was undertaken.
52 patients referred to coronarography for suspicion or evaluation of ischemic disease, were submitted to this technique.
The study was completed in 44 patients (applicability rate of 84,7%). The results obtained showed a sensitivity, specificity and diagnostic accuracy for the regional wall motion abnormalities echocardiographically detected, of 88%, 68% and 79%, respectively. When electrocardiographic changes or presence of angina during atrial pacing were added to echocardiographic data, sensitivity increased to 96%. In 41 patients in which a conventional stress test was available, sensitivity was 55% electrocardiographically, 33% clinically and 68% globally.
It is concluded that transthoracic two-dimensional echocardiography during atrial pacing is a safe, highly sensitive method for coronary artery disease detection. The limitations of the method for its routine clinical application are also analysed.
Revista Espa de Cardiologia 06/1994; 47(5):308-15. · 2.53 Impact Factor
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ABSTRACT: We report six cases of Morgagni hernia diagnosed and operated on in our pediatric surgical unit during a 14-year period. Four children were younger than 1 year and two between 1 and 2 years. Predominance in males was found. Associated congenital pathology was present in 3 children (Down's syndrome, diaphragmatic relaxation, criptorquidia and pyelo-ureteral stenosis). Predominant clinical features were respiratory infections and vomiting. In only one patient clinical onset was with respiratory distress. Plain chest x-ray was the most used diagnostic procedure. In all cases barium enema was performed to confirm the clinical diagnosis. Most frequent surgical approach was a midline supra-umbilical laparotomy. Diaphragmatic defect was left sided in 3 children and right-sided in the other 3. Transverse colon and liver were the most frequent herniated viscera. Postoperative follow-up showed no complications or recidives.
Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva 04/1993; 83(3):151-5. · 1.55 Impact Factor
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ABSTRACT: Seventy consecutive patients with recurrent unexplained syncope were evaluated by use of an up-right tilt-table test for 45 minutes (with or without an infusion of isoproterenol) in an attempt to reproduce symptoms. There were 42 males and 28 females with a mean age of 49 +/- 20 years (range 7-86), and with a mean symptoms duration of 35.2 +/- 16 months. All the patients underwent clinical examination which includes cardiological and neurological evaluation. Some tilt positive patients received therapy with either transdermal scopolamine, metoprolol or clonidine, the efficacy of which was evaluated by another tilt-table test. Syncope occurred in sixteen patients (22.9%), during the baseline tilt associated with hypotension (2 patients), bradycardia-asystolia (3 patients), or both (11 patients). In 11 patients with normal baseline tilt test, isoproterenol infusion was used appearing 4 new cases of abnormal response. Some patients who had positive test results, eventually became tilt-table negative by therapy (5 out of 8 patients treated with scopolamine, 5 out of 6 patients with metoprolol, and 3 out of 5 patients with clonidine). Time before syncope during tilt-test was increased with therapy, being of 45 min in normalized cases, and increasing from 11.9 +/- 16 basal to 34.4 +/- 17 min with scopolamine (p < 0.05), to 40 +/- 12 min with metoprolol (p < 0.05) and to 33.7 +/- 16.7 min with clonidine (p = NS). We conclude that upright tilt-table alone or combined with isoproterenol infusion is an useful test in the diagnosis of vasovagal syncope and in the evaluation of therapy.
Revista Espa de Cardiologia 01/1993; 46(1):28-33. · 2.53 Impact Factor
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ABSTRACT: We report two cases of duodenal atresia associated with corporal symmetry changes. The one of them presented a "situs inversus total" and the other one a Ivermak syndrome. The association between duodenal atresia and Ivermak syndrome has a very low incidence. We have not found references with respect to the association between duodenal atresia and "situs inversus totalis". The embryo-genetic hypothesis that could relate both anomalies are discussed. Perhaps are not caused by chance.
Cirugía pediátrica: organo oficial de la Sociedad Española de Cirugía Pediátrica 08/1992; 5(3):184-6.
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ABSTRACT: The results of the echocardiographic evaluation of 72 patients with hypertrophic cardiomyopathy are presented. We have measured left ventricular wall thickness in 8 different segments and classified our patients in 6 types according to the hypertrophy extent. Moreover, we have evaluated by Doppler ultrasound the presence and severity of mitral regurgitation and the left ventricular inflow and outflow. The hypertrophy cardiomyopathy pattern was symmetric in 8 patients, apical in five, and asymmetric in 31. According to Maron classification, asymmetric cardiomyopathy was I type: 4 patients, II type: 16, III type: 11, and IV type: 0 patients. There were left ventricular outflow obstruction (greater than 25 mmHg) in 26 patients (36.1%). This obstruction was more frequent in II and III type hypertrophic cardiomyopathy and we found significative relationship between septal posterior segment hypertrophy and left ventricular outflow obstruction. Ventricular inflow showed bad distensibility pattern in 45 patients (62.5%). Mitral regurgitation was mild, moderate and severe in 25, 15, and 4 patients. Left ventricular outflow obstruction, bad distensibility pattern and mitral regurgitation were independent each other.
Revista Espa de Cardiologia 02/1991; 44(1):11-7. · 2.53 Impact Factor
