Maria Sanchez-Ledesma

Harvard Medical School, Boston, Massachusetts, United States

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Publications (22)78.75 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: Patients with mitral stenosis with severe pulmonary hypertension constitute a high-risk subset for surgical commissurotomy or valve replacement. The aim of the present study was to examine the effect of elevated pulmonary vascular resistance (PVR) on percutaneous mitral valvuloplasty (PMV) procedural success, short- and long-term clinical outcomes (i.e., mortality, mitral valve surgery, and redo PMV) in 926 patients. Of the 926 patients, 263 (28.4%) had PVR ≥4 Woods units (WU) and 663 (71.6%) had PVR <4 WU. Patients with PVR ≥4 WU were older and more symptomatic and had worse valve morphology for PMV. The patients with PVR ≥4 WU also had lower PMV procedural success than those with PVR <4 WU (78.2% vs 85.6%, p = 0.006). However, after multivariate adjustment, PVR was no longer an independent predictor of PMV success nor an independent predictor of the combined end point at a median follow-up of 3.2 years. In conclusion, elevated PVR at PMV is not an independent predictor of procedural success or long-term outcomes. Therefore, appropriately selected patients with rheumatic mitral stenosis might benefit from PMV, even in the presence of elevated preprocedural PVR.
    The American journal of cardiology 05/2013; · 3.58 Impact Factor
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    ABSTRACT: To determine the association between different comorbidities and other clinical conditions with mortality in patients with multiple diseases (PMD) suffering from chronic obstructive pulmonary disease (COPD). Patients with COPD and PMD criteria were included in an observational, prospective and multicentrer study. Data on age, gender, Charlson index, Barthel index, Lawton-Brody index, Pfeiffer test, sociofamilial Gijon scale, education level, hospitalizations during the previous 3 and 12 months and survival at one year were collected. The relationship between the variables and mortality were established by means of a univariate analysis and logistic regression model. A total of 688 PMD with COPD and mean age of 77.9 years were included. The mean score one the Charlson index was 3.99 (2.07). The most frequent comorbidities were heart failure (59%), diabetes (48%), myocardial infarction (29%), moderate kidney failure (22%), cerebrovascular disease (19%), hypertension (71%), anemia (62%), atrial fibrillation (34%), dyslipidemia (28%) and obesity (21%). A total of 26% of patients were dependent for activities of daily living, 47% needed a caregiver and 54% were at risk of having social problems. At one year, 258 patients (37%) had died. The Charlson index, dependency for activities of daily living and anemia were associated with mortality and hypertension and capacity for reading and writing were associated with survival. Comorbidity and discapacity are two prognostic factors in COPD patients.
    Revista Clínica Española 11/2011; 211(10):504-10. · 2.01 Impact Factor
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    ABSTRACT: Objectives To analyze the prevalence of risk factors (RF) and cardiovascular diseases, and evaluate their treatment in a multicenter population of patients with multiple conditions (PMC).
    International Journal of Multiphase Flow - INT J MULTIPHASE FLOW. 01/2011; 28(2):39-47.
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    ABSTRACT: AimsTo determine the association between different comorbidities and other clinical conditions with mortality in patients with multiple diseases (PMD) suffering from chronic obstructive pulmonary disease (COPD).
    Revista Clinica Espanola - REV CLIN ESPAN. 01/2011; 211(10):504-510.
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    ABSTRACT: To analyze the differences in anatomical, clinical and echocardiographic characteristics of women and men undergoing PMV and to evaluate the relationship between sex, PMV success, and immediate and long-term clinical outcome. Rheumatic mitral stenosis (MS) is predominantly a disease of middle-aged women. Percutaneous mitral valvuloplasty (PMV) has become the standard of care for suitable patients. However little is known about the relationship between sex, PMV success, and procedural outcome. We evaluated measures of procedural success and clinical outcome in consecutive patients (839 women and 176 men) who underwent PMV. Despite a lower baseline echocardiographic score (7.47 ± 2.15 vs. 8.02 ± 2.18, P = 0.002), women were less likely to achieve PMV success (69% vs. 83%, adjusted OR 0.44, 95% CI 0.27-0.74, P = 0.002), and had a smaller post-procedural MV area (1.86 ± 0.7 vs. 2.07 ± 0.7 cm(2), P < 0.001). Overall procedural and in-hospital complication rates did not differ significantly between women and men. However, women were significantly more likely to develop severe MR immediately post PMV (adjusted OR 2.41, 95% CI 1.0-5.83, P = 0.05) and to undergo MV surgery (adjusted HR 1.54, 95% CI 1.03-2.3, P = 0.037) after a median follow-up of 3.1 years. Compared to men, women with rheumatic MS who undergo PMV are less likely to have a successful outcome and more likely to require MV surgery on long-term follow-up despite more favorable baseline MV anatomy.
    Catheterization and Cardiovascular Interventions 11/2010; 77(1):115-20. · 2.51 Impact Factor
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    M Sánchez-Ledesma, I Cruz-González
    Revista Clínica Española 09/2010; 210(8):413-9. · 2.01 Impact Factor
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    ABSTRACT: To determine if hyperglycemia on admission correlates to infarct size measured by single-photon emission computed tomography (SPECT) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We evaluated 347 STEMI patients who underwent primary PCI. Infarct size was determined by SPECT on Day 5. The population was divided into: hyperglycemia (glycemia on admission >11mmol/L) or non-hyperglycemia (<or=11mmol/L) regardless of diabetic status. 61 (17.6%) patients presented with hyperglycemia on admission. There were no significant differences in baseline characteristics or in PCI characteristics between the two groups. Final TIMI 3 flow was achieved in 81.7% of patients with hyperglycemia vs 85.7% of patients with non-hyperglycemia (p=0.43). The infarct size was larger in the hyperglycemia group (6 [2-14]% vs 8.5 [3-18.25]%; p=0.016). A multivariate linear regression analysis showed that hyperglycemia on admission was an independent predictor of infarct size at Day 5 post-MI (p=0.004). In patients with STEMI treated with primary PCI, hyperglycemia on admission is associated with larger infarct size determined by SPECT.
    Diabetes research and clinical practice 04/2010; 88(1):97-102. · 2.74 Impact Factor
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    ABSTRACT: Percutaneous mitral valvuloplasty (PMV) is an effective therapy in patients with significant mitral stenosis. Few studies have examined the effect of mitral regurgitation (MR), a frequent periprocedural finding, on PMV outcomes. We examined the effects of pre- and postprocedural MR after PMV. Contrast left ventriculography was performed before and after PMV, and the MR severity was assessed using Sellers' classification. Clinical, hemodynamic, and morphologic variables were collected for all patients. Consecutive patients (n = 876) undergoing a first PMV procedure at a single tertiary center were evaluated. An increasing preprocedural MR severity was associated with reduced PMV success (no MR, 75%; 1+ MR, 65%; 2+ MR, 44%; p <0.0001), increased in-hospital mortality (0.6% vs 2.8% vs 4.9%, respectively; p = 0.007), and other complications. Increasing grades of pre- and postprocedural MR predicted, independently and in a grade-dependent manner, the composite outcome of mortality, mitral valve surgery, or redo PMV (preprocedural MR >or=1+, relative risk [RR] 1.4, 95% confidence interval [CI] 1.2 to 1.8; preprocedural MR >or=2+, RR 1.6, 95% CI 1.1 to 2.4; postprocedural MR >or=1+, RR 1.6, 95% CI 1.2 to 2.0; postprocedural MR >or=2+, RR 2.2, 95% CI 1.7 to 2.7; and postprocedural MR >or=3+, RR 4.6, 95% CI 3.4 to 6.2, respectively). In conclusion, increasing pre- and postprocedural MR grades independently predicted the long-term clinical outcomes after PMV. Patients with moderate preprocedural MR, in particular, appeared to have suboptimal short- and long-term outcomes, necessitating careful monitoring and early referral for mitral valve surgery, when appropriate.
    The American journal of cardiology 10/2009; 104(8):1122-7. · 3.58 Impact Factor
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    ABSTRACT: It is estimated that 5% of the hypertensive patients are resistant to conventional antihypertensive therapy. Polymorphisms in the endothelial nitric oxide synthase (NOS3) gene have been associated with high blood pressure levels, but not with resistant hypertension. The aim of the present study was to investigate if the -786T>C and G894T (Glu298Asp) polymorphisms of the NOS3 gene were associated with resistant hypertension. A prospective case-control observational study was performed. From a series of 950 consecutive patients followed up during 42 months, 48 patients with resistant hypertension were detected. 232 patients with controlled high blood pressure were also included. No differences were observed in the distribution of G894T (Glu298Asp) NOS3 genotypes between the resistant hypertension group and the controlled hypertension patients. However, genotype -786CC was more frequent in the group of patients with resistant hypertension (33.3%) than in the group of patients with controlled high blood pressure (17.7%) (p 0.03). Furthermore carriers of allele T (-786TC and -786TT) were more frequent in patients with controlled hypertension (82.3%) than those with resistant hypertension (66.7%) (Multivariate analysis; RR 2.09; 95% CI 1.03-4.24; p 0.004). Our results indicate that genotype -786CC of the NOS3 gene increase the susceptibility to suffer resistant hypertension, which suggest that resistance to conventional therapy could be determined at the endothelial level.
    BMC Cardiovascular Disorders 09/2009; 9:35. · 1.46 Impact Factor
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    ABSTRACT: Percutaneous mitral valvuloplasty (PMV) success depends on appropriate patient selection. A multifactorial score derived from clinical, anatomic/echocardiographic, and hemodynamic variables would predict procedural success and clinical outcome. Demographic data, echocardiographic parameters (including echocardiographic score), and procedure-related variables were recorded in 1085 consecutive PMVs. Long-term clinical follow-up (death, mitral valve replacement, redo PMV) was performed. Multivariate regression analysis of the first 800 procedures was performed to identify independent predictors of procedural success. Significant variables were formulated into a risk score and validated prospectively. Six independent predictors of PMV success were identified: age less than 55 years, New York Heart Association classes I and II, pre-PMV mitral area of 1 cm(2) or greater, pre-PMV mitral regurgitation grade less than 2, echocardiographic score of 8 or greater, and male sex. A score was constructed from the arithmetic sum of variables present per patient. Procedural success rates increased incrementally with increasing score (0% for 0/6, 39.7% for 1/6, 54.4% for 2/6, 77.3% for 3/6, 85.7% for 4/6, 95% for 5/6, and 100% for 6/6; P < .001). In a validation cohort (n = 285 procedures), the multifactorial score remained a significant predictor of PMV success (P < .001). Comparison between the new score and the echocardiographic score confirmed that the new index was more sensitive and specific (P < .001). This new score also predicts long-term outcomes (P < .001). Clinical, anatomic, and hemodynamic variables predict PMV success and clinical outcome and may be formulated in a scoring system that would help to identify the best candidates for PMV.
    The American journal of medicine 06/2009; 122(6):581.e11-9. · 4.47 Impact Factor
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    ABSTRACT: Reduction in expression levels of glutathione S-transferase (GST) mu type 1 (GSTM1) in stroke-prone spontaneously hypertensive rats has recently been reported. GSTM1 genotype was evaluated in 49 patients with resistant hypertension and compared with selected patients with controlled hypertension (n=232) and healthy participants (n=110). Null GSTM1 genotype occurred more frequent in patients with resistant hypertension than those with controlled hypertension (57.1 vs 39.7%; P=0.03; RR 1.96; 95% CI 1.04-3.69) suggesting that null GSTM1 genotype may predispose to resistant hypertension.
    Journal of human hypertension 04/2009; 23(8):556-8. · 2.80 Impact Factor
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    ABSTRACT: The aim of the study is to examine the effect of concomitant aortic regurgitation (AR) on percutaneous mitral valvuloplasty (PMV) procedural success, short-term, and long-term clinical outcome. No large-scale study has explored the impact of coexistent AR on PMV procedural success and outcome. Demographic, echocardiographic, and procedure-related variables were recorded in 644 consecutive patients undergoing 676 PMV at a single center. Mortality, aortic valve surgery (replacement or repair) (AVR), mitral valve surgery (MVR), and redo PMV were recorded during follow-up. Of the 676 procedures performed, 361 (53.4%) had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups in the preprocedure characteristics, procedural success, or in the incidence of inhospital adverse events. At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = .22), MVR rate (P = .69), or redo PMV incidence (P = .33). The rate of AVR was higher in the moderate AR group (0.9% vs 1.9% vs 13%, P = .003). Mean time to AVR was 4.5 years and did not differ significantly between patients with no AR, mild AR, or moderate AR (2.9 +/- 2.1 vs 5.7 +/- 3.6 vs 4.1 +/- 2.5 years, P = .46). Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate AR remain good candidates for PMV.
    American heart journal 08/2008; 156(2):361-6. · 4.65 Impact Factor
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    ABSTRACT: Argatroban is increasingly used in patients with heparin-induced thrombocytopenia. Although the recommended activated clotting time during percutaneous coronary intervention is 300-450 s, this recommendation is based on the limited data. This single-center, retrospective study evaluated the efficacy (composite of death, myocardial infarction, or urgent revascularization) and safety (evaluated by thrombolysis in myocardial infarction major bleeding) of argatroban during percutaneous coronary intervention according to activated clotting time levels. Patients were divided into three groups according to the activated clotting time achieved during the procedure (<300s, 300-450s, and >450 s). In this study, 120 consecutive patients with confirmed or suspected heparin-induced thrombocytopenia received argatroban (241 +/- 104 mug/kg bolus, followed by a 18 +/- 10 microg/kg per min infusion) during percutaneous coronary intervention. The indication for percutaneous coronary intervention was stable angina in 20% of patients, unstable angina or non-ST elevation myocardial infarction in 58%, and ST elevation myocardial infarction in 22%. An adjunctive glycoprotein IIb/IIIa inhibitor was used in 56 patients (46.7%). When divided into three groups on the basis of the activated clotting time (<300, 300-450, >450 s), no significant difference was observed between the groups in the efficacy endpoint, which occurred in 9.8% (6/61) of patients in the group with activated clotting time less than 300 s, 19.6% (9/46) of patients in the group with activated clotting time 300-450 s, and 7.7% (1/13) of patients in the group with activated clotting time more than 450 s (P = 0.58). The rate of major bleeding was higher in the group of patients with activated clotting time more than 450 s (1.6, 0, and 15.4% patients, respectively; P = 0.006). These results suggest that in patients undergoing percutaneous coronary intervention, argatroban provides adequate anticoagulation with a low bleeding rate, when activated clotting time is maintained below 450 s.
    Blood Coagulation and Fibrinolysis 07/2008; 19(5):401-4. · 1.25 Impact Factor
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    ABSTRACT: There is limited experience with the use of argatroban in combination with glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitor in acute coronary syndrome (ACS) patients with heparin-induced thrombocytopenia (HIT) undergoing percutaneous coronary intervention (PCI). This single-center, retrospective study evaluated the efficacy (composite of death, myocardial infarction, or urgent revascularization) and safety (evaluated by TIMI major bleeding) of the argatroban with or without a GPIIb/IIIa inhibitor during PCI. Among 102 consecutive ACS patients (71.6% unstable angina or NSTEMI and 28.4% STEMI) who received argatroban (239 +/- 104 microg/kg bolus, followed by a 17 +/- 11 microg/kg/min infusion) for confirmed or suspected HIT during PCI, 52 patients (51%) received a GPIIb/IIIa inhibitor simultaneously (86% integrilin, 10% tirofiban, 4% abciximab) and 50 patients (49%) did not. There was no difference between the groups in the efficacy endpoint, which occurred in nine patients (17.3%) who received GPIIb/IIIa inhibitor and in eight patients (16%) who did not (P = 0.70). TIMI major bleeding occurred in three (5.8%) patients in the GPIIa/IIIb inhibitor group versus 0 (0%) patients in the argatroban alone group (P = 0.085). In patients with suspected or confirmed HIT undergoing PCI for ACS, argatroban with or without GPIIb/IIIa appears to provide adequate anticoagulation and is well tolerated with a low rate of bleeding.
    Journal of Thrombosis and Thrombolysis 05/2008; 25(2):214-8. · 1.99 Impact Factor
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    ABSTRACT: Patients with atrial fibrillation are at an increased risk of having a cardioembolic stroke. Most of the thrombi responsible for these ischemic events originate in the left atrial appendage (LAA). Several surgical and percutaneous endovascular techniques have been explored to occlude the LAA. As an alternative of the surgical closure, percutaneous exclusion of the LAA is a new approach used to prevent strokes in high-risk patients with AF and contraindication to long-term oral anticoagulant therapy. Currently, two devices have been developed specifically for percutaneous occlusion of the LAA the PLAATO system and the WATCHMAN filter system. Although the Amplatzer septal occluder device was not originally intended to occlude the LAA it has been used with success in our centre for this purpose. We present an illustrative case of a patient with AF no longer suitable for chronic OCA referred for percutaneous exclusion of the LAA. She was treated successfully with an Amplatzer septal occluder. Although our experience with this device holds promise, future trials will be necessary to explore this strategy.
    International journal of cardiology 03/2008; 134(1):e1-3. · 7.08 Impact Factor
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    ABSTRACT: Hemorrhage is the most common and best-recognized complication of heparin treatment. However, a potentially more dangerous complication is the development of heparin-induced thrombocytopenia (HIT). All patients exposed to heparin, irrespective of the dose and route of administration, are at risk of developing HIT. It is due to the formation of antibodies against the heparin-platelet factor 4 complex, which cause secondary activation of platelets, coagulation and, finally, increased thrombin production. The main symptom is the sudden onset of thrombocytopenia involving a drop in the platelet count to less than 50% of the basal level, with or without the appearance of thrombotic complications some 5 to 14 days after the start of heparin therapy. Heparin-induced thrombocytopenia can be detected early in patients receiving heparin by monitoring the platelet count. Demonstration of heparin-dependent platelet activation using an antigen or functional assay confirms the clinical diagnosis. Once the diagnosis of HIT has been confirmed serologically or there is a high level of suspicion of HIT, heparin must be suspended and treatment with an alternative anticoagulant should be considered. This review contains a discussion of the diagnosis and treatment of this syndrome.
    Revista Espa de Cardiologia 11/2007; 60(10):1071-82. · 3.20 Impact Factor
  • Circulation 07/2007; 115(25):e643-5. · 15.20 Impact Factor
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    ABSTRACT: La complicación más común y reconocida del trata-miento con heparina es la hemorragia, pero una compli-cación potencialmente más peligrosa es el desarrollo de la trombocitopenia inducida por heparina (TIH). Todos los pacientes expuestos a heparina de cualquier tipo y a cualquier dosis están en riesgo de TIH. Se debe a la for-mación de anticuerpos contra el complejo heparina-factor plaquetario 4, que secundariamente activa las plaquetas y la coagulación y finalmente produce un aumento en la formación de trombina. El síntoma principal es una trom-bocitopenia brusca, con una caída del 50% en el recuen-to plaquetario con respecto a los valores basales, y/o complicaciones trombóticas que aparecen 5 a 14 días tras el comienzo del tratamiento con heparina. La monito-rización del recuento plaquetario en pacientes que reci-ben heparina permite el diagnóstico precoz de la TIH. La demostración de la activación plaquetaria dependiente de heparina con métodos antigénicos o funcionales confirma el diagnóstico. Una vez que se confirma serológicamente el diagnóstico de TIH o la sospecha es alta, se debe sus-pender el tratamiento con heparina y valorar el tratamien-to con anticoagulantes alternativos. En esta revisión se discute los aspectos diagnósticos y el manejo de este síndrome.
    Rev Esp Cardiol. 01/2007; 60:1071-82.
  • Medicina Clínica 08/2005; 125(5):198-9. · 1.40 Impact Factor
  • Medicina Clinica - MED CLIN. 01/2005; 125(5):198-199.

Publication Stats

48 Citations
1 Download
1k Views
78.75 Total Impact Points

Institutions

  • 2008–2013
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2010–2011
    • Hospital Universitario de Salamanca
      Helmantica, Castille and León, Spain
  • 2007–2010
    • Massachusetts General Hospital
      • Division of Cardiology
      Boston, MA, United States
  • 2009
    • Baylor College of Medicine
      • Section of Cardiology
      Houston, TX, United States