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2. ACTUALIZACIONES

La célula muscular lisa ¿prima donna en la ateroesclerosis?
Smooth muscle cell. Prima donna in atheroesclerosis?
LORENA PÉRSICO, DANIEL GRANA, CARLOS NAVARI, JOSÉ MILEI

Se han descripto lesiones preateroescleróticas a edad muy temprana, aun en la vida fetal, que se relacionaron con el tabaquismo materno. Las células musculares lisas juegan un papel protagónico tanto en el desarrollo como en la progresión de la ateroesclerosis. Este trabajo resalta el papel fundamental de las células musculares lisas en el desencadenamiento de la lesión ateroesclerótica y en la progresión de la enfermedad.

Atherosclerosis is the most important cause of death in adults (> 50 years old) in developed countries. However “pre-atherosclerotic lesions” have been described even during fetal life, and they have been associated with maternal tobaccoism. In fact, this is the most important perinatal risk factor in the development of the disease. The smooth muscle cells (SMCs) have a leading role in early and in established atherosclerosis. They can migrate from the media to the intima by ameboid movements; once there, they proliferate and differentiate contributing to the development and progression of the disease. SMCs autoregulate their proliferation (autocrine stimulation) by releasing mitogenic factors, vg. PDGF, after proto-oncogene activation (c-fos and p53) in the nucleus. In the intima, SMCs undergo phenotypic modulation, switching from contractile cells (non-proliferative) to synthetic cells (proliferative); the changes are not only evident at the morphological level but there are variations in the expression of the cytoskeletal proteins. It has been demonstrated that atherosclerotic plaques have a monoclonal origin involving SMCs and its enhancement of the proliferative activity related to different chromosomic alterations.
This work highlights the main role of SMCs in the triggering of atherosclerotic lesions and the progression of the disease.

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Prueba de esfuerzo para pacientes de bajo riesgo en Unidades de Dolor Torácico.
Exercise testing of low risk patients in chest pain units
EZRA A. AMSTERDAM, DOUGLAS J. KIRK, DEBORAH B. DIERCKS, SAMUEL D. TURNIPSEED, ROBERT R. LEWIS

La Unidad de Dolor Torácico ha sido creada para la evaluación de pacientes de bajo riesgo que se presentan con síntomas sugestivos de síndrome coronario agudo. El protocolo de diagnóstico acelerado (PDA), en el cual la prueba de esfuerzo es un elemento clave, ha sido desarrollado dentro de esas unidades para mejorar la evaluación clínica. Estudios realizados en la última década han establecido la utilidad de la prueba de esfuerzo precoz, que ha demostrado ser segura, precisa y costo-efectiva en este escenario. Los protocolos específicos para protocolo de diagnóstico acelerado varían, pero la mayoría requiere un período de observación de 6 a 12 horas por ECG seriados y marcadores cardíacos de lesión para excluir infarto y angina inestable de alto riesgo antes de proceder a la prueba de esfuerzo. Sin embargo, en la Unidad de Dolor Torácico de la UC Davis Medical Center nuestro enfoque comprende una prueba de esfuerzo inmediata, sin el proceso tradicional de descarte de un infarto. Una extensa experiencia ha validado esta estrategia en una población grande y heterogénea. Se puede esperar que la estrategia óptima para evaluar pacientes de bajo riesgo que se presentan en el departamento de emergencias con dolor torácico continuará evolucionando, basada en la investigación actual y en el desarrollo de nuevos métodos.

Chestpain units have been developed to provide safe, accurate and cost-effective management of low risk patients with symptoms suggestive of acute coronary syndrome. This low risk group comprises the majority of patients presenting to the emergency department chest pain. They are characterized by absence of objective evidence of myocardial ischemia/injury in whom an accelerated diagnostic protocol can identify those requiring admission and those who can be safely discharged with outpatient follow-up. An intrinsic, final component of an accelerated diagnostic protocol is a stress test after an initial assessment for acute coronary syndrome. The primary stress test has been treadmill exercise evaluation, although imaging studies are utilized in many centers.

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3. ARTICULOS ORIGINALES

Fibrilación auricular en el postoperatorio de cirugía de revascularización miocárdica. Prevalencia, factores predisponentes y resultados del tratamiento.
Atrial fibrillation in the postoperative period of coronary artery bypass grafting. Prevalence, risk factors and result of the treatment
CRISTINA DEL R. SANTA CRUZ LÓPEZ, ADOLFO DRAGO, HÉCTOR R. PASCUA, ROBERTO LOLO, RICARDO E. RONDEROS, JOSÉ COMO BIRCHE

Este trabajo analiza la prevalencia de fibrilación auricular en el postoperatorio de cirugía de revascularización miocárdica, identificando los factores predisponentes y evaluando los efectos del tratamiento con amiodarona para su reversión. Se estudiaron 103 pacientes sometidos a cirugía de revascularización miocárdica en el período de un año, 26 de los cuales presentaron fibrilación auricular de más de una hora de evolución, 19 de ellos entre el segundo y el tercer día de la cirugía. Se analizaron factores de riesgo cardiovascular, comorbilidades, presencia de infarto de miocardio preoperatorio, función ventricular izquierda y tamaño de la aurícula izquierda medidos con ecocardiografía, procedimientos de revascularización percutáneos o quirúrgicos previos, y variables postoperatorias: revascularización miocárdica completa, requerimiento de balón de contrapulsación aórtica, complicaciones en general y en particular (cardiológicas, respiratorias, neurológicas y renales), sangrado y desórdenes hidroelectrolíticos. Los factores predisponentes identificados fueron la diabetes y la presencia de complicaciones postoperatorias en general; el tratamiento con amiodarona por vía intravenosa resultó efectivo.

 

The onset of atrial fibrillation (AF) in the postoperative period of coronary artery bypass grafting (CABG) is very frequent. Atrial fibrillation prevalence is not still clearly determinate. The presence of this arrhythmia is associated with an increase of morbidity, mortality, and a longer and expensive hospital stay.
The risk factors for AF development after CABG are multiple. There is no agreement about its prevention and treatment.
The objective of this study was to review the prevalence of AF, risk factors and the use of amiodarone in our institution.
Over a period of one year, 220 cardiac surgeries were performed at the San Juan de DiosHospital (La Plata). One hundred and three (47%) of them underwent CABG. These patients were included in this prospective study. In the postoperative period, twenty six (25%) developed AF longer than one hour, nineteen of them on the second and third postoperative day.
Risk factors were reviewed. Risk cardiovascular factors, no cardiac morbidities, prior myocardial infarction, left ventricular function, left atrium area, prior angioplasty or CABG were included. Complete revascularization, use of intraaortic balloon pumping, as well as postoperative complications (cardiovascular or not) were considered.
Diabetes was a significant predictor of AF development in postoperative period (OR 3.03; CI 95% 1.04-8.04). Patients with AF were older, but age didn’t reach significance as a predictive risk factor in univariate analysis.
Postoperative complications were a risk factor of AF onset in the ICU stay (OR 3.14; CI95% 1.13-8.82). Parenteral amiodarone was started as treatment of postoperative AF as soon as it was detected. Initial dose was 5-10 mg/kg during 45 minutes, and was continued until the first 24 hours at a dose of 0.7 mg/kg/min. This drug was used in twenty five patients (96%). Reversion to sinus rhythm was achieved in all of them within the first day. In one patient was employed electric cardioversion because of hemodynamic unstability. There were no complications, and the hospital stay of these patients were no longer than non AF group (8.2 ± 4.3 days). No deaths were observed in AF group.
Conclusions: the incidence of postoperative AF in CABG is high. Postoperative complications and DBT were identified as risk factors for AF development. Amiodarone was useful for rhythm management after AF onset.

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Evolución de la estenosis valvular aórtica leve. Estudio ecocardiográfico.
Evolution of mild valvular aortic stenosis. An echocardiography study
FERNANDO J. MORELL, RICARDO RONDEROS, EDUARDO ESCUDERO, DIOMEDES CORNELLI

La evolución natural de la estenosis aórtica leve y sus predictores pronósticos no han sido bien definidos. Se presenta un estudio prospectivo de 21 pacientes con diagnóstico de estenosis aórtica leve de origen ateroesclerótico definida por la presencia de soplo sistólico eyectivo en el examen físico y un área valvular de entre 1,2 y 1,7 cm2 determinada mediante la fórmula de ecuación de la continuidad en el examen ecocardiográfico con Doppler. Se concluye que la estenosis valvular aórtica leve de origen ateroesclerótico tiene una evolución lenta, que las válvulas con mayor componente fibrocálcico presentan una progresión de la severidad más rápida y que factores de riesgo como la insuficiencia renal y la diabetes, así como la hipertensión arterial, serían predictores de evolución.

Introduction. The natural history of mild aortic stenosis and its predictors for evolution have not been well defined and most of them are unclear because they have not been analyzed as an individual group.
Method. 21 patients with diagnosis of mild aortic stenosis of atherosclerotic origin, defined by the presence of ejective systolic murmur at the physical exam and a 1.2-1.7 cm² valvular area analyzed by the continuity equation in a complete Doppler echocardiogram, were included prospectively. According to the valvular fibrocalcic component, patients were divided in two groups to be analyzed as independent predictor of progression. Cardiovascular risk factors in the whole group and in a subgroup with and without calcium were analyzed.
Results. For the whole group the mean annual progression after a mean follow up of 30±12.5 months was 0.,044±0.04 m/seg for the maximal velocity jet, 0.13±0.17 mmHg for the maximal gradient and 0.1±0.12 mmHg for the mean gradient. The mean annual progression for the valvular area was 0.08±0.1 cm². When we analyze the subgroup with and without calcium, we find a faster progression in the subgroup with calcium with a mean annual rate of 0.13±0.08 cm² vs 0.04±0.02 cm² (p 0,03) for the valvular area, 0.35±0.18 m/sec vs 0.09±0.18 m/sec for the maximal jet velocity (p 0.05),  0.22±0.12 mmHg vs 0.06±0.08 mmHg (p 0.04) for the peak gradient and 0.14±0,12 mmHg vs 0.06±0.12 mmHg (p NS) for the mean gradient. The renal insufficiency (p 0.02) and diabetes (p 0.01) have shown to be predictors of progression in the whole group, meanwhile arterial hypertension has been significant predictor of progression in the subgroup with calcium when we analyzed cardiovascular risk factors.
Conclusion. The present study shows that atherosclerotic mild aortic stenosis is a benign pathology with slow progression. Those valves with more fibrocalcic components have a faster severity progression and cardiovascular risk factors like renal insufficiency and diabetes for the general group and arterial hypertension for the more fibrocalcific subgroups are predictors of evolution.

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4. CASOS CLINICOS

Cirugía del aneurisma del seno de Valsalva.
Surgical treatment of sinus of Valsalva aneurysm
ESTEBAN A. SERRANO, GABRIEL H. BASSO, CARLOS E. FLORES,
JOSÉ H. COMO BIRCHE 

El propósito de este trabajo fue estudiar la prevalencia de aneurismas del seno de Valsalva y la seguridad de su resolución quirúrgica en la etapa sin complicaciones. Se analizaron 344 cirugías cardíacas, realizadas en el lapso de un año. Sólo 3 (0,87%) de los pacientes presentaron aneurisma del seno de Valsalva. Todos los casos fueron resueltos quirúrgicamente. La cirugía se realizó sin complicaciones postoperatorias ni mortalidad.

The sinus of Valsalva aneurysm is a dilatation in the union of the aortic media with fibrous aortic annulus. From Jan 1-Dec 31/2004, 344 patients underwent cardiac surgery: three of them (0,87%) had sinus of Valsalva aneurysm. Two patients had congenital aneurysm communicated to the right ventricle. The other was healed endocarditis with a recess in the left sinus. The defect was  corrected with simple closure in two cases and dacron patch in one of them. There was no mortality and no postoperative complications. Although the small sample, the surgery was an effective and safe procedure.

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Fenómeno de no reflujo en un caso de infarto agudo de miocardio con reperfusión espontánea.
No reflow phenomenon in an acute myocardial infarction with spontaneous reperfusion
EDUARDO E. MAGARIÑOS, GERMÁN E. SOLIOZ, HUGO F. LONDERO

En este artículo presentamos un caso de fenómeno de no reflujo durante un infarto agudo de miocardio espontáneamente reperfundido, discutiendo las alternativas diagnósticas y terapéuticas de esta entidad.

In the present article a no reflow phenomenon case during an acute myocardial infarction with spontaneous reperfusion is described. Diagnostic and therapeutics alternatives are discussed.

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XXXII Congreso Nacional de Cardiología 2014

VIII Congreso Virtual de Cardiología 2013

Campaña "100.000 Corazones" Edición 2013

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Editorial Electrónica
de FAC





XXXI Congreso
Nacional de Cardiología
Buenos Aires


31 Mayo,
1-2 Junio 2013



7vo. Congreso Virtual
de Cardiología

1º Setiembre al
30 Noviembre, 2013