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Many patients with severe aortic stenosis never undergo surgical treatment for various reasons. Apart from the standard risks, some patients face an additional problem: their carrying of a mechanical mitral valve. In these patients, transcatheter aortic valve implantation is a therapeutic option. The literature contains only few reports of this procedure being performed (usually transapically) in such patients. This paper reports the cases of 3 patients with severe aortic stenosis, all carrying a mechanical mitral valve and at high surgical risk, all of whom were implanted by transcatheter aortic valve implantation with an Edwards aortic valve prosthesis. All procedures were successful with no complications encountered.

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.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.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 ± 12.2mm. 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.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 circulation. Methods 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4 ± 3.62 years (range 3-13) and 23.5 ± 8.74 Kg (range 12-38) in the submammary group, and 5.5 ± 2.04 years (range 3-9) and 19.7 ± 5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports. Results No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups ( P >.05). Conclusions 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent.

This paper describes the general situation regarding heart transplantation in Spain and the results obtained using the technique, incorporating data for the year 2004. In 2004, 294 heart transplants were carried out, which brings the total number of procedures performed since 1984 to 4680. Clinically, the typical heart transplant recipient in Spain is male, aged around 50 years, has blood group A, has non-revascularizable coronary artery disease, and is in NYHA functional class IV/IV. The percentage of emergency heart transplantations was 35%, which is higher than in the previous year (29%), and higher than the mean for the preceding 5 years (22%). The early mortality rate was 10%, which is lower that the mean for the preceding 5 years (13%). After combining the results for 2004 with those of previous years, the probability of survival at 1, 5 and 10 years was 80%, 70% and 60%, respectively. When the survival rates for different time periods were analyzed, a significant improvement could be seen in the last 5 years, with recent survival rates being 85% and 72% at 1 and 5 years, respectively. The most frequent cause of death in the first month was acute graft failure; in the first year, infection and rejection; and, over the long term, tumors and a combination of graft vasculopathy and sudden death. A comparative analysis of survival rates showed that long-term results in Spain are slightly better than those published in the world literature. Moreover, survival has tended to improve gradually in recent years.

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.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.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, p0.01). In 3 to 36 months of follow-up (13.9 11 months), all patients preserved sinus rhythm.Left atrial reduction seems to be an effective and easily applied alternative method for treating mitral valve disease with chronic atrial fibrillation.

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.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.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 walked300 meters and 0% for those who reached500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times100 ms or atrial diameters5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p0.0001.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.

The large amount of information on rates of acute coronary syndrome accumulated in Spain over the last two decades is summarized in this paper, which also estimates the number of cases expected in 2002 and the trend for 1997 to 2005.Published information on the situation in the 90's was reviewed and summarized. We present the incidence of acute myocardial infarction (AMI), and an estimate of the absolute number of patients expected for various acute coronary syndromes in each autonomous community in Spain in 2002, along with the trend for 1997 to 2005.Approximately 68,500 patients will suffer AMI in 2002 and 40,989 of them will be hospitalized, while the rest will die before admission. A further 24.9% of admitted patients will not survive 28 days. Slightly less than half will be younger than 75 years old, an age with a better prognosis (28-day mortality 38.8%). Approximately 33,500 patients with unstable angina will be admitted, and 4.5% of them will die within 3 months of admission. Assuming the incidence of AMI remains stable, the absolute number of cases will increase by 2.28% yearly (9,847 cases in total) and hospitalizations for acute coronary syndromes will increase by 1.41% (8,817 cases in total) between 1997 and 2005.Ischaemic heart disease generates increasing demand for health care in Spain. Case fatality is high among the approximately 68,500 AMI patients, given that scarcely two thirds will have been hospitalized in 2002.

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.The aim of this paper is to review our initial experience with percutaneous balloon pericardiotomy for the treatment of patients with recurrent pericardial effusion.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.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.Percutaneous balloon pericardiotomy is an easy and useful technique to manage patients with large recurrent pericardial effusion with a low r

Geographical differences in hospitalizations and mortality for heart failure serve to estimate the potential for reducing the associated hospital and demographic burden on the population. Accordingly, the objective of this paper is to analyze the geographic variation in heart failure hospitalizations and mortality in Spain during the period of 1980-1993, and to examine their potential determinants.Data on the primary diagnosis of heart failure were taken from the National Hospital Morbidity Survey and National Vital Statistics. Information on determinants of heart failure were obtained from large-scale nationally representative surveys conducted by the National Statistics Office.The period of 1980-1993 witnessed a decrease in geographical differences in heart failure hospitalizations and mortality. Theoretically, however, heart failure hospitalizations and mortality among persons agedor = 45 years could still be further reduced by 60% and 30% respectively. In the period of 1989-1993 heart failure hospitalizations were correlated (p0.05) with ischaemic heart disease hospitalizations and the number of beds/1,000 inhabitants. Heart failure mortality showed a statistically significant correlation (p0.05) with ischaemic heart disease mortality, illiteracy and unemployed status.There is a great potential for a reduction in the hospital and demographic burden of heart failure in Spain. Control of ischaemic heart disease and a reduction in the geographical differences in socio-economic status would probably contribute to lessening the healthcare burden of heart failure in Spain.

This paper is a comprehensive and critical review of the updated information available in Spain for the elderly population on the epidemiology of cardiovascular diseases. Clinical (coronary heart disease, heart failure, and cerebrovascular disease) and subclinical (left ventricular hypertrophy, carotid stenosis) cardiovascular diseases are reviewed. Prevalence and distribution of major classical cardiovascular risk factors such as hypertension, hyperlipidemia, diabetes mellitus and smoking and information on new risk factors such as microalbuminuria or abdominal obesity are also presented. The article is also focused on the high rates of morbidity, mortality and the burden of handicap in this age group in comparison with middle-aged people. Finally we call attention to the few and inconsistent population data available for some of the mentioned topics in our country, particularly the lack of specific figures of incidence and risk rates from cohort studies of elderly people in Spain.

Coronary by-pass grafting is a well established procedure for ameliorating ischemic coronary disease. From time to time it is necessary to re-operate these patients. The objective of our paper is to present our experience in this field. Retrospective analysis of 128 patients operated on between February 1978 and November 1996, has been analyzed. The mean age was 57.4 +/- 0.7 years. 77.2 +/- 5 months elapsed between operations. Stable angina (20.4%) or unstable angina (76.3%), myocardial infarction (48%) and congestive heart failure (17%) were the predominant clinical manifestations.Hospital mortality was 10.9% (14 patients) and in the follow-up there were 16 deaths (14%). Perioperative myocardial infarction was the main cause of in-hospital mortality. In the follow-up there were 4 deaths due to myocardial infarction and another 4 patients died from neoplasms. Perioperative myocardial infarction was present in 9.3% (12 patients)a) Re-do coronary by-pass grafting is still a good procedure for solving myocardial ischemia in spite of a higher mortality and morbidity than in the original operation. b) There is no progression in the number of patients according to our experience, probably due to better techniques and the frequent actions by an intervention cardiologist. c) The long-term results are good enough, but with a higher mortality.

In Spain ischemic heart disease mortality was increasing prior to 1975 and has decreased since 1975. This trend is common to both genders. The goal of this paper is to separate the genetic, environmental and competitive risk factors influencing this evolution.The Gompertz function was adjusted cross-sectionally to age-specific mortality due to ischemic heart disease for each year from 1951 to 1992. The Gompertzian longitudinal analysis was applied to the coefficients obtained to estimate the effect due to environmental and competitive factors.Ischemic heart disease in Spain is a Gompertzian disease with an intersection point at 67 years for men and 40 years for women. Environmental factors were increasing before 1975 and have decreased since then. However, the competitive factors decreased in men since 1980 and in women since 1951 on.The evolution of risk factors (smoking, hypercholesterolemia and hypertension) is responsible for the major proportion of ischemic disease mortality changes. Treatment of instaured ischemic disease has a low influence.

This paper reviews the current questions and the new aspects related to Infective Endocarditis in elderly patients. Four points are emphasized: a) epidemiological changes during the last decades, b) clinical features and diagnostic challenges of infective endocarditis in the elderly, c) mortality and prognosis, and d) preventive and therapeutic measures that must be taken into account.

In the last few years the has been an enormous development in noninvasive testing in the field of clinical cardiology. In fact, excellent monographs on each one of these techniques have been published elsewhere, but fewer publications exist that treat the topic of their indications and use in an integrated way, except for in the most common clinical situations. In this paper, the treatment of patients who present chest pain, stable and unstable angina is discussed, including the study of postinfarction patients. Furthermore, the role of noninvasive tests in the detection of coronary heart disease in women and in patients with left bundle branch block is thoroughly analyzed; as well as their usefulness after surgical or percutaneous coronary revascularization and in patients with peripheral vascular disease.