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Although direct balloon angioplasty has emerged as an alternative to thrombolytic therapy in patients with acute myocardial infarction, reocclusion and restenosis rates are limiting factors. We postulated that these limitations could be partly overcome by primary stenting of the responsible lesion.Since January/94 we have studied 59 patients with acute myocardial infarction who were treated in the early phase (3.1 +/- 2 hours since the onset of symptoms) by elective Palmaz-Schatz stent implantation. No adjunctive thrombolytic therapy was associated. Two patients were in cardiogenic shock and were treated under percutaneous cardiopulmonary support. At cardiac catheterization a left ventriculography and coronary angiograms were obtained. Then, mechanical recanalization of the responsible lesion was performed. If the angiographic anatomy was considered suitable, a stent was implanted at the lesion.The infarct related artery was the left anterior descending in 29 patients, the circumflex in 14 and the right coronary artery in 16. At baseline conditions, 40 patients had a totally occluded artery and 19 showed a TIMI-grande 1 antegrade flow. One patient had an early clinical recurrence 4 days later, which required an additional divided Palmaz-Schatz stent at the distal portion of the lesion, in order to seal a residual dissection. All remaining patients had a favourable clinical course without major complications. Immediately after treatment the minimal lumen diameter was 3.2 +/- 0.4 mm and no residual stenosis was detectable at the treated segment. Six-month angiographic reevaluation was performed in all 29 (49%) eligible patients. Restenosis (50% stenosis) was detected in 6 out of the 29 evaluated patients (21%).Primary stent implantation in selected patients with an evolving myocardial infarction provides good initial and 6-month results.

Coronary stenoses at ostial level, when treated by balloon angioplasty, show a primary success rate much lower than those located in other parts of the coronary tree. Balloon dilation of lesions located at the left anterior descending ostium is associated with a high degree of restenosis, elastic recoil and the possibility of retrograde dissection to the left main coronary artery. Simpson atherectomy may be considered a percutaneous alternative in this particular location, since this technique produces fewer incidents of elastic recoil than balloon dilation. The purpose of the present study is to evaluate directional atherectomy in the treatment of patients with symptoms deriving from severe to stenosis at the origin of the left anterior descending artery.From a total number of 302 patients treated by Simpson atherectomy, we have analyzed 45 with severe stenosis at the left anterior descending ostium (less than 3 mm from its origin). The mean age was 54 +/- 12 years. Eighty two percent of the patients were male. The clinical condition was stable in unstable in 34; eleven had had a previous myocardial infarction. Six had multivessel coronary disease, all of them underwent combined balloon angioplasty of other segments. The treated lesion was native in 41 patients and previously dilated by balloon (restenosis) in 4. Two patients needed balloon predilation with 2 and 2.5 mm to facilitate the pass of the atherocatheter. The size of the Simpson atherocatheter was mainly 7F (78%). The weight of the resected arteriosclerotic material was 11 +/- 7 mg.Primary success (residual stenosis40% without major complications) was obtained in 42 out of 45 patients (93%); 3 patients (7%) had major complications (1 death, 1 emergency surgery, and 1 non-Q wave myocardial infarction). A follow-up angiography study was available in 31 patients 7 +/- 8 months later. Restenosis was evidenced in 12 (39%).Simpson atherectomy for left anterior descending artery ostial lesions is an effective transluminal alternative in selected patients providing a high rate of primary success (93%) and an acceptable restenosis rate (39%).

The aim of our study was to assess the spontaneous outcome of acute myocarditis associated with severe cardiac dysfunction in children, as well as to compare these features with those occurring in adult patients.Fifty patients consecutively diagnosed of acute myocarditis during the last 7 years in our hospital were studied; 15 patients were children younger than 14 years, and 35 were adults. Immunosuppressive therapy was not used in any patient.Mean age was 2 +/- 3 years in children, ranging from 2 months to 12 years. One patient required temporary pacing for a third-degree atrioventricular block, while the remaining 14 children had severe congestive heart failure, with a left ventricular ejection fraction of 30 +/- 12% (16 to 44%). After a mean follow-up of 21 +/- 26 months, only 3 children died, at 1, 4 and 10 months after the initial diagnosis. Death was sudden in all 3 patients. Left ventricular ejection fraction rose to 45 +/- 14% at 1 month after diagnosis, and to 58 +/- 15% at the end of follow-up. Unfavorable evolution (death or evolution to chronic dilated cardiomyopathy, with a left ventricular ejection fraction45%) occurred in 6 children (40%) at 1 month after diagnosis and in only 4 (25%) at the end of follow-up. The 9 children with 1-month favorable outcome were alive and had an ejection fraction45% at long-term, while only 2 of the 6 children with 1-month unfavorable outcome were alive and had an ejection fraction45% at long-term. Only the 3 children who died had an ejection fraction30% at 1-month. Favorable outcome was more frequent in children that in adult patients with acute myocarditis (75% versus 46%).The outcome of acute myocarditis with severe cardiac dysfunction was favorable in a majority of pediatric patients; this favorable evolution was less frequent in adults. Patients in whom left ventricular ejection fraction did not increase at short-term had a higher risk of death, and they should probably be considered for heart transplantation.

To determine the factors related to the formation of spontaneous echo contrast in left atrium.We have analyzed our series of 1,066 patients undergoing transesophageal echocardiography until December 1991. It was found in left atrium in 387 patients (36%) and was associated with another pathology in 99%. We defined spontaneous echo contrast as mild in 64% and severe in 36%.The prevalence of spontaneous echo contrast was greater in patients with atrial fibrillation (p0.001), mitral stenosis (p0.001), double mitral lesion (p0.001), prosthesis (p0.001), embolism (p0.05) and a dilated left atrium (left atrial dimension greater than 60 ml) (p0.01). The presence of mitral regurgitation made it less frequent (p0.05). Thrombi were visualized in 104 patients and they were more frequent in the presence of spontaneous echo contrast. Severe spontaneous echo contrast was significantly more frequent in patients with atrial fibrillation (p0.001), mitral stenosis (p0.05) and thrombi (p0.001).Spontaneous echo contrast in left atrium is a common finding in transesophageal studies and it is associated with another pathology in 99%. It is more frequent in patients with atrial fibrillation, mitral stenosis, embolism or prosthesis. Left atrial enlargement is one of the more important factors. It is less frequent in patients with mitral regurgitation. Thrombi are less frequent in patients without spontaneous echo contrast. Severe spontaneous echo contrast is significantly associated with mitral stenosis, atrial fibrillation and left atrial thrombi.

A case of Listeria monocytogenes endocarditis in a patient with mitral prosthetic valve, left atrial thrombus and colonic adenocarcinoma is reported. Vegetations were not demonstrated by transesophageal echocardiography and the clinical course was benign and without complications. Cure was achieved with antibiotic therapy, and surgery was not required. These features suggest that atrial thrombus could be the source of infection.

Three cases of symptomatic bradycardia due to topical ocular timolol administration are reported. Two patients had syncope related to atrioventricular block, and the other one complained of dizziness due to sinus bradycardia. Heart disease was not present in any case, although a right bundle branch block was observed in one patients. A normal sinus rhythm resumed in all patients after discontinuation of timolol.

The case of a patient in whom acute pericarditis was the initial manifestation of an idiopathic hypereosinophilia is reported. Endomyocardial abnormalities were not found by echocardiography. Response to prednisone therapy was good; symptoms, pericardial effusion and eosinophilia early disappeared after therapy. Some clinical aspects of this uncommon disease are discussed.

A case of intracranial mycotic aneurysm due to culture-negative infective endocarditis involving a patient with hypertrophic cardiomyopathy is reported. The patient, a 22-year-old woman with no history of known prior disease, had fever, headache and focal neurologic symptoms 3 days before admission. An echocardiogram performed after admission disclosed an obstructive hypertrophic cardiomyopathy and a gross vegetation on septal leaflet of mitral valve. Cerebral angiography revealed a mycotic aneurysm involving a peripheral branch of the left middle cerebral artery. Causal agent was not identified, and empiric treatment with penicillin G and streptomycin achieved medical cure and disappearance of the aneurysm 2 weeks later. Four months after endocarditis had been cured, the patient was electively operated because of progression of mitral regurgitation. Six months later, she is asymptomatic.

Two cases of Brucella melitensis pericarditis are reported. Pericardial involvement was the first and almost only manifestation of brucellosis in the first patient while in the second, a significant pericardial effusion was discovered on a routine echocardiogram performed in a patient with clinically florid brucellosis. Some etiopathogenic aspects of this uncommon etiology are discussed.

Distinctive features of patients over 70 years with acute myocardial infarction (AMI) are studied. Between May 1988 and April 1989, 420 patients with AMI were admitted to our hospital; 118 of them (28.5%) were older than 70 years. In this group of patients, proportion of woman was higher (36 vs 16%, p less than 0.001), while incidence of smoking and hypercholesterolemia was lower (41 vs 64%, p less than 0.001; and 15 vs 29%, p less than 0.05). There was no differences in other risk factors, prior history of coronary heart disease (angina, AMI, coronary surgery), or general features of AMI (location, proportion of painless AMI, non-Q-wave AMI, evolved AMI, initial admission to coronary care unit or general ward, time from the beginning of symptoms to admission, residual ejection fraction). The incidence of severe complications was superior between older patients: shock, 17 vs 7% (p less than 0.05); Killip class III/IV, 30 vs 13% (p less than 0.001); and fascicular blocks: 26 vs 16% (p less than 0.05). Hospital mortality was also higher in older patients, 25.5 vs 14% (p less than 0.01). No patients older than 70 years received fibrinolytic therapy, and only one underwent coronary artery surgery (22% and 15%, respectively, in younger patients). Coronary arteriography, exercise test, radionuclide ventriculography and Holter monitoring were also performed before discharge in a lesser proportion in older patients. We conclude that mortality and severe complications were higher between patients over 70 years with AMI. We think that mortality could be decreased by a more aggressive management in, at least, selected groups of older patients with AMI.

Almost 90% of primary acute pericarditis are idiopathic. Between specifics forms, a very low percentage of cases are due to chronic rheumatic diseases. A case of adult Still's disease (juvenile chronic rheumatoid arthritis) with acute pericarditis being the first clinical manifestation (besides fever and general syndrome) is presented. Therapy with oral prednisone was rapidly effective, and pericardial effusion resolved after 3 weeks of treatment, as echocardiography showed.

We study 40 patients, 55 +/- 7 years old with acute myocardial infarction treated early by thrombolytic therapy (20 STK and 20 rt-PA). All patients were angiographically studied in the following conditions: 1) baseline, before initiating therapy. 2) Three hours after treatment. 3) Twenty four hours later. 4) Before discharge. The infarct related artery was patent 24 hours after treatment in 31 patients (78%); five of them were patent before treatment, and we observed an early reperfusion in 20 patients (57%) and late reperfusion in 6 patients (17%). The number of patients with angiographic evidence of intraluminal thrombus decreased progressively through conditions while the grade TIMI of coronary perfusion increased in the absence of reocclusion. Final regional wall motion of infarct related myocardial zones and their degree of recovery were significantly higher in recanalized patients, as compared with non-reperfused patients. Similarly, left ventricular functional recovery was higher in patients with antegrade of collateral flow to the infarct area, as compared with totally occluded patients.

The present article describes the cooperative experience Córdoba-Las Palmas since 1983 in 123 patients with congenital right or left ventricular outflow obstructions who were treated by percutaneous balloon dilatation. Seventy of them had pulmonary stenosis (63 valvular and seven supravalvular types); two had pulmonary atresia, 25 valvular aortic stenosis and 27 discrete subaortic stenosis. In patients with valvular pulmonic stenosis the gradient and the right ventricular pressure decreased significantly. No significant changes were observed in the degree of pulmonary regurgitation. One neonate died. No other major complications occurred. After a mean follow up of 3 +/- 2 years, we did not observe significant changes in the degree of pressure relief. The mean residual gradient is 26 +/- 19 mmHg. In our 21 patients out of the neonatal period with valvular aortic stenosis the gradient and the left ventricular pressure dropped significantly. Progression of aortic regurgitation in more than I grade was observed in 4 patients (19%), although only one (5%) progressed to grade III. There were no major complications in this group. After a mean follow up period of 24 +/- 17 months they persist with the obtained pressure relief and same degree of valvular competence. All 4 neonates with critical aortic stenosis had unsuccessful dilations and they died, wether after ulterior surgery or without it. In 27 patients with discrete subaortic stenosis the gradient and the left ventricular pressure decreased markedly, without significant changes in valve competence. There were no related major complications. After dilation, a broken and mobile membrane was frequently seen. At follow up (24 +/- 18 months), 6 patients (22%) had restenosis; five of them were successfully redilated. The remaining 21 patients persist with a reduced residual gradient (24 +/- 7 mmHg) and without significant changes in valve competence.

This article describes our findings on a prospective and cooperative study (Córdoba-Las Palmas) in 203 patients with mitral stenosis who underwent balloon valvuloplasty using a retrograde transarterial technique. We analyzed the immediate and mid-term results, and studied the factors determining an optimal result and those related to the new appearance or worsening of mitral incompetence after the procedure. On the other hand, we analyzed the results of mitral valvuloplasty in patients with previous mitral surgery, mild mitral stenosis and patients dilated while having an acute pulmonary edema. We observed a marked decrease in mean mitral gradient (17 +/- 7 to 6 +/- 3 mmHg; p less than 0.001) as well as a significant increase in mitral valve area (1.02 +/- 0.4 to 2.04 +/- 0.7 cm2; p less than 0.001). Echo-Doppler follow-up did not show significant changes in the residual mitral valve gradient. Multivariate analysis selected, as independent predictors of an optimal result, the presence of a pliable valve and the absence of basal mitral regurgitation. On the other hand, the presence of a lower ejection fraction, an older age and a higher baseline left ventricular endiastolic volume were independent factors determining progression of mitral regurgitation. In patients with previous mitral surgery, the clinical, echo and hemodynamic profiles, as well as the immediate results, were similar to those observed in patients with unoperated mitral stenosis. In the subgroup of mild mitral stenosis, we observed and optimal result in all cases, without major complications. Mitral valvuloplasty was dramatically effective in 8 patients treated during acute pulmonary edema.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the usefulness of the infarct size determined by serial creatine kinase (CPK) measurements in patients with early reperfusion, we have studied 189 patients meaning in age 59.2 +/- 8.6 years, with acute myocardial infarction treated with streptokinase (STK); 81 of them by intracoronary route (group A), and 108 by intravenous administration (group B). In the group A we performed serial angiographic studies in the following conditions: baseline, immediately after STK infusion and before hospital discharge. In group B we performed only one angiographic control 5 +/- 3 days after. In patients with reperfusion, the parameters of left ventricular function correlated with cumulative creatine kinase release (MAX-CPKr) by linear regression in both groups. We observed a tendency to closer correlations in patients with left anterior descending or circumflex artery as the infarct related artery, in patients without previous infarction and in those who did not receive electrical shock for ventricular arrhythmias. In patients with unsuccessful reperfusion (n = 11), we also obtain a significant correlation (r = 0.72) between ejection fraction and MAX-CPKr. The slope of the regression line (b = 7.7 X 10(-5) was steeper (p less than 0.05) than that observed in recanalized patients, who were evaluated within the first 3 days (b = 2.2 X 10(-5), after 8 +/- 5 days (b = 2.7 X 10(-5), or before discharge, at 22 +/- 9 days (b = 2.6 X 10(-5).(ABSTRACT TRUNCATED AT 250 WORDS)

To add data on controversy between the advantages and inconveniences of using either unipolar or bipolar modes for permanent cardiac pacing, we have studied 15 patients. In all of them a CPI Delta-925 (DDD) pulse generator was implanted. Non invasive pacing threshold values in volts were measured at 0.05, 0.08 and 0.1 ms for each chamber programmed either to unipolar or bipolar mode, at 1, 2, 3, 4, 5, 6, 7, 8, 14, 21, 30, 60, 90, 120, 180 and 365 days after the implant. Sensing thresholds were measured at the same time. For any pulse width the mean pacing thresholds in atrium and ventricle increase uniformly, reaching its maximum values between the days 8 and 14 after the implant and decreases to a stable value between 90 and 120 days after the implant, without statistically significant differences for both: unipolar and bipolar modes. Pacing thresholds (V +/- SD) for 0.05 ms in the day 365th were in atrium: unipolar 2.85 +/- 0.79, bipolar 3.35 +/- 0.92 (p = 0.56) and ventricle: unipolar 3.92 +/- 1.01, bipolar 4.36 +/- 1.35 (p = 0.58). Sensing thresholds in atrium and ventricle decreases from the 1st day after the implant with the minimum mean value the day 8th, increasing eventually. No statistically significant differences were found between sensing unipolar/bipolar mode at each chamber. Sensing thresholds (mV +/- SD) in the 365th day were in atrium: unipolar 4.40 +/- 2.07, bipolar 4.10 +/- 2.10 (p = 0.82) and ventricle: unipolar 11.20 +/- 3.63, bipolar 10.10 +/- 5.13 (p = 0.71).for every single patient: 1) There are not statistically significant differences in the evolution of unipolar and bipolar pacing thresholds both in atrium and ventricle, regarding rate and time of increase, maximum value, rate of decrease and stable chronic values. 2) There are neither statistically significant differences regarding unipolar and bipolar sensing in atrium and ventricle respect to rate of decrease, time and value of the minimum and stable chronic values.