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Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

A B S T R A C T Ventricular arrhythmias are important contributors to morbidity and mortality in patients with coronary artery disease. Ventricular fibrillation accounts for the majority of deaths occurring in the acute phase of ischemia, whereas sustained, monomorphic ventricular tachycardia due to reentry generated in the scar tissue develops most often in the setting of healed myocardial infarction, especially in patients with lower left ventricular ejection fraction. Despite determinant advances in population education and myocardial infarction management, the ventricular tachycardia risk in the overall population with coronary artery disease continues to be a major problem in clinical practice. The initial evaluation of a patient presenting with ventricular tachycardia requires a 12-lead electrocardiogram, which can be helpful to confirm the diagnosis, suggest the presence of potential underlying heart disease, and identify the location of the ventricular tachycardia circuit. An invasive electrophysiologic study is usually crucial to determine the mechanism of the arrhythmia once induced and to provide guidance for ablation. The approach for ventricular tachycardia ablation depends on several factors, including inducibility, sustainability, and clinical tolerance of ventricular tachycardia. The paper also reviews other therapeutic options for patients with ventricular tachycardia associated with coronary artery disease, including antiarrhythmic drug therapy, surgical ablation, and current implantable cardioverter-defibrillator indications.

Introduction and objectives: The increasing incidence of abdominal aortic aneurysm (AAA), mainly due to the aging population, and its mortality of 85-90% in the event of rupture justify opting for early diagnosis and elective treatment to repair it. The main aim of this paper is to analyze the utility of transthoracic echocardiography (TTE) in the study of infrarenal aorta and AAA screening. Methods: The study included 512 patients (309 men and 203 women) consecutively assessed by TTE and, where possible, abdominal ultrasound for any reason in a cardiology department. Results: An AAA was detected in 25 patients (5.1%), the minimum age at diagnosis was 55 years, the ratio of men to women was 7.3:1 and the mean diameter of the aneurysms was 39.5 12.2 mm. Risk factors associated with AAA were to current and former smoking, age, and presence of femoral murmur. The TTE results were equivalent to those of abdominal ultrasound. All patients with AAA studied by coronary angiography showed significant coronary lesions. Conclusions: It is feasible and useful to complement conventional TTE with the study of the infrarenal aorta for AAA screening in patients visited at the department of cardiology. This study should be performed mainly in patients 55 years old or with risk factors to develop an AAA.

Introduction and objectives: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal

Despite diastolic dysfunction is recognized to play a major role in the pathophysiology of heart failure, the importance of an accurate diagnosis and treatment of this syndrome in clinical practice is poorly established. Recent publications suggest that diastolic dysfunction is the primary cause of heart failure in 30-50% of patients. Several studies also show that, in a significant number of patients with systolic dysfunction, diastolic function is the major determinant of their symptomatic status, their response to treatment and their outcome. Other preliminary data suggest that diastolic dysfunction is an important cause of exercise intolerance in patients with chronic hypertension. This paper discusses the most recent concepts related to the mechanisms, the diagnosis and the treatment of diastolic dysfunction based on diagnostic imaging techniques.

The clinical relevance of cardiac embolism a potential cause of stroke is progressively increasing, mainly due to the recent progress in diagnostic imaging. In the present paper, we update and review the state of the art of the different etiologies currently accepted of a cardiac source of stroke. Furthermore, we review the clinical role of different image techniques, emphasizing the doubts and realities of each particular approximation.

Contrast angiography has been used for nearly five decades to evaluate the severity of coronary lesions. However, when attempting to distinguish between intermediate coronary lesions able or unable to produce ischemia, the technique has several limitations. A large number of patients undergo cardiac catheterization without prior evaluation of coronary perfusion by non-invasive tests. This number is likely to increase in the coming years, because current recommendations favor the invasive treatment of acute coronary syndromes. This has triggered marked interest in new diagnostic techniques capable of assessing the physiological significance of intermediate lesions in the catheterization room. This paper reviews the different techniques currently available for scientifically assessing the significance of such lesions. The advantages and limitations of each are discussed.

Background. Recurrent symptomatic pericardial effusion can complicate different cardiac and extracardiac diseases. When recurrent pericardial effusion after drainage with conventional catheter techniques occurred the creation of a pericardial window by open surgery used to be the unique treatment available until the recent development of percutaneous balloon pericardiotomy. Objective. The aim of this paper is to review our initial experience with percutaneous balloon pericardiotomy for the treatment of patients with recurrent pericardial effusion. Patientes and method. Five patients with recurrent pericardial effusion have been treated with percutaneous pericardiotomy until now. Four patients had malignant pericardial effusion secondary to metastasis of extracardiac tumors, in one patient recurrent pericardial effusion was idiopathic. In all patients percutaneous balloon pericardiotomy was performed with a pediatric valvuloplasty balloon catheter, through a subxiphoid approach. Results. Successful drainage and balloon pericardiotomy was achieved in all patients without severe complications. In all cases only one pericardial site was dilated. Minor complications were registered, which included mainly mild pleural effusion occurring in all patients with spontaneous resolution. During a mean follow-up period of 8.6 ± 6.5 months (range 2 to 18 months) there were no recurrences of effusion or tamponade. Two patients died, 1 month and 9 months after the procedure, due to their malignant condition. Conclusions. Percutaneous balloon pericardiotomy is an easy and useful technique to manage patients with large recurrent pericardial effusion with a low rate of complications.

Received Accepted for publication For many years, the evaluation of the extent and severity of coronary artery disease has been mainly anatomical, carried out by coronary angiography. However, this technique has methodological limitations and interobserver variability is considerable. Quantification of coronary reserve with pressure guidewires and intracoronary Doppler now provides more precise physiologic evaluation of coronary circulation. Myocardial perfusion single proton emission computed tomography and echocardiography, combined with stress and/or pharmacological challenge testing, though they are only semiquantitative techniques, also offer appropriate complements to coronary angiography in the functional evaluation of coronary patients. The aim of this paper is to discuss the clinical value of these techniques.

Introduction and objectives. Mitral valve disease often is accompanied by chronic atrial fibrillation, especially when the left atrium is enlarged. Mitral valve surgery alone cannot resolve the arrhythmia in most cases. Several surgical techniques have been proposed. We have used surgical left atrial reduction and pulmonary vein isolation to eliminate chronic atrial fibrillation associated with mitral valve disease. The aim of this paper is to report our experience with this new surgical concept. Patients and method. Twenty-three patients (18 women and 5 men, mean age 44.1 ± 14.7 years) with mitral valve disease and chronic atrial fibrillation for more than 3 months underwent surgery. Mitral valvuloplasty was performed in 11 cases, and mitral valve replacement in 12. Left atrial reduction was used to eliminate chronic atrial fibrillation in all cases. Results. There was no operative mortality. Three patients (13%) had recurrent atrial fibrillation between postoperative days 6 and 8. No atrioventricular conduction disturbances were observed. An important reduction in left atrial size was evident on echocardiography (4.8 ± 0.77 vs. 8.1 ± 1.47 cm, p < 0.01). In 3 to 36 months of follow-up (13.9 ± 11 months), all patients preserved sinus rhythm. Conclusions. Left atrial reduction seems to be an effective and easily applied alternative method for treating mitral valve disease with chronic atrial fibrillation.

Introduction and objectives. Multiple clinical and echocardiographic parameters have been shown to have prognostic value in cases of left ventricular dysfunction. The purpose of this paper was to evaluate the relative predictive power of such parameters. Methods. Ninety-one patients with systolic dysfunction were prospectively studied. Functional status was evaluated using the New York Heart Association classification and the 6-minute walking test. Other clinical and biochemical parameters were assessed, and an anatomic and functional echocardiographic study was performed. Results. Mean follow-up was 16.5 months (SD: 6.95). Eighteen patients died and two underwent heart transplantation (cardiac death 22%). Multiple regression analysis showed that the only independent predictor of death was functional status. Functional classes I and II showed a 16-month mortality rate of 10%, class III 40% and class IV 83%. The mortality rate was 67% for patients who walked 500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times 5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p < 0.0001. Conclusions. Functional status is the main predictor of outcome in patients with systolic dysfunction, whether assessed subjectively or estimated objectively by a walking test. Among echo-Doppler parameters, the deceleration time of the E wave and left atrial diameter gave similar prognostic information, although with less statistical significance. They can confirm or substitute the prognosis obtained by the functional classification.

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.

During the last 20 years, the principal objective in hypertrophic cardiomyopathy research has been the refinement of algorithms for the identification and treatment of patients at risk of sudden death. Sudden death is an important problem in hypertrophic cardiomyopathy, with an incidence of 4-6% in referral populations and approximately 1% in non-referral centers and because it affects young and often asymptomatic patients. We now know that hypertrophic cardiomyopathy is not a single disease, but a group of diseases caused by mutations in genes encoding different sarcomeric proteins. The phenotypic expression depends on multiple modifying genetic and environmental factors. Even though genetic testing is not presently a practical approach in hypertrophic cardiomyopathy risk stratification, it is important to consider new genetic data in the prognostic evaluation of patients. In this paper, we review the published data on risk stratification in hypertrophic cardiomyopathy and we set forth our opinion with regard to the available therapeutic options and their indications in the prevention of sudden death.

The 1998 Nobel Prize in Physiology and Medicine has been awarded jointly to North-American scientists, Dr Robert F. Furchgott, Louis J. Ignarro and Ferid Murad, for their discoveries in relation to "nitric oxide as a signalling molecule in the cardiovascular system". This has raised an important polemic because of the exclusion the South-American scientist, now nationalized British, Dr. Salvador Moncada. This short historical review examines some of the fundamental contributions to the knowledge in this field. It shows the sequence of the discoveries and the communication of them to the scientific community by the rewarded scientists and by Dr. Moncada. It is based on some fundamental publications in order to better understand this story, which does not coincide with the writing in 1996 by the Lasker Prize Committee, and which in 1998 was re-written again by the Nobel Committee of the Swedish Academy. More than 90 universities, academies and societies have acknowledged Dr. Moncada up to now with priority in the discovery of the fact that nitric oxide is released by endothelial cells, and the revealing of its metabolic way. More than 20,000 citations of their fundamental papers endorse in the scientific community his primacy in this field. Even Robert Furchgott, author of the brilliant discovery of the endothelium derived relaxing factor, that opened this field to the science, declared about the award of the 1998 Nobel Prize: "I feel that the Nobel Prize Committee could have made an exception this year and chosen a fourth person, Salvador Moncada (to share the prize)".

Changes in health systems are determining new hospital organization forms. The patient focused hospital suppose a new radical design of hospital processes from the patient's viewpoint. This paper defines the re-engineering process of the Cardiology and Cardiovascular Surgery Services of the Hospital Clinic of Barcelona in order to develop and Institute. The change consists fundamentally in a reorganization of the direction organs, creating a staff commission and director. The chief nursing and chief management report to the director. Also, a patients admission and management unit, that manage the beds infrastructure of both services has been developed. The first year results show a reduction of the length of stay and an increase in the in-hospital and external activity.