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Introduction and Objectives: Strategies are needed to reduce health care costs and improve patient care. The objective of our study was to analyze the safety of outpatient implantation of cardioverter-defibrillators., Methods: A retrospective study was conducted in 401 consecutive patients who received an implantable cardioverter-defibrillator between 2007 and 2012. The rate of intervention-related complications was compared between 232 patients (58%) whose implantation was performed in the outpatient setting and 169 patients (42%) whose intervention was performed in the inpatient setting., Results: The mean age (standard deviation) of the patients was 62 (14) years; 336 (84%) were male. Outpatients had lower left ventricular ejection fraction and a higher percentage had an indication for primary prevention of sudden death, compared to inpatients. Only 21 outpatients (9%) required subsequent hospitalization. The rate of complications until the third month postimplantation was similar for outpatients (6.0%) and inpatients (5.3%); P = .763. In multivariate analysis, only previous anticoagulant therapy was related to the presence of complications (odds ratio = 3.2; 95% confidence interval, 1.4-7.4; P < .01), mainly due to an increased rate of pocket hematomas. Each outpatient implantation saved approximately €735., Conclusions: Outpatient implantation of implantable cardioverter-defibrillators is safe and reduces costs. Close observation is recommended for patients receiving chronic anticoagulation therapy due to an increased risk of complications., (Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

This article contains a review of some of the most significant advances in cardiac arrhythmias that have taken place in the last year, particularly those concerning the most common clinical conditions associated with the risk of arrhythmia, such as sudden cardiac death, atrial fibrillation and syncope, and genetically determined and hereditary heart disease, as well as advances concerning the principal nonpharmacologic treatments, such as catheter ablation, and the use of implantable defibrillators and cardiac resynchronization therapy.

Methadone is a synthetic opioid that has been used successfully to treat heroin addiction and chronic pain. It is usually well tolerated and has few side effects. Recently, an association with torsade de pointes has been reported. We present 4 cases of torsade de pointes during methadone treatment.

Ventricular preexcitation, due to an accessory pathway that creates an electrical connection between the atria with the ventricles, can provide a substrate for a variety of arrhythmogenic syndromes, from paroxysmal AV junctional tachycardia, to the facilitation or aggravation of atrial tachyarrhythmias that can lead to sudden death. However, statistics show that the most frequent situation is for the individual to remain asymptomatic throughout his or her life. In the asymptomatic individual, population-based studies with very long follow-up periods indicate that the risk of sudden death is minimal. Acute therapy for tachyarrhythmias is based on adenosine/verapamil for regular, narrow-QRS tachycardias and procainamide/electrical cardioversion for preexcited tachyarrhythmias. Chronic pharmacologic therapy with antiarrhythmic drugs is not recommended because its efficacy is not well proven and its risk of side effects can be considerable. In symptomatic patients, the treatment of choice is catheter ablation, with an efficacy of 93%, a complication rate of 1% and a mortality rate of 1 per thousand. Whether catheter ablation should be recommended for asymptomatic individuals remains controversial. The authors recommend that these individuals should be followed with regular clinical evaluation, and that catheter ablation should be advised only for those who become symptomatic.

Background: Mitral valve pathology is frequently associated with atrial dilation and fibrillation. Mitral surgery allows immediate surgical atrial remodeling, and in those cases in which sinus rhythm is achieved, it is followed by late remodeling. The aim of this study was to investigate the process of postoperative atrial remodeling in patients with permanent atrial fibrillation who undergo mitral surgery., Patients and Method: In a prospective randomized trial, 50 patients with permanent atrial fibrillation and dilated left atrium, repaired surgically, were divided into two groups: group I, 25 patients with left atrial reduction and mitral surgery, and group II, 25 patients with isolated valve surgery. The characteristics of both groups were considered homogeneous in the preoperative assessment., Results: After a mean follow-up of 31 months, 46% of the patients in group I versus 18% in group II regained sinus rhythm (p = 0.06). Atrial remodeling with shrinkage occurred in patients who recovered sinus rhythm, with larger changes in group II (-10.8% left atrial volume reduction in group I compared to -21.5% in group II; p < 0.05). The atrium became enlarged again in patients whose atrial fibrillation did not remit (+16.8% left atrial volume increase in group I versus +8.4% in group II; p < 0.05)., Conclusions: Mitral surgery produces a postoperative decrease in atrial volume, especially when reduction techniques are used. Late left atrial remodeling was influenced by the type of atrial rhythm and postoperative surgical volume.

Background: Atrial fibrillation is frequent in surgical patients with cardiac valvulopathies. Radiofrequency energy applied by means of surgical probes permits the reproduction of atriotomies described in the maze surgical procedure for the ablation of atrial fibrillation in a fast, safe and efficient way. This study presents our initial experience in treatment of chronic atrial fibrillation through radiofrequency performed in patients with surgical cardiac valvulopathies., Patients and Method: From June to November 2000, 10 patients, with surgical indications of valvulopathy, were intraoperatively treated through radiofrequency for its atrial fibrillation. Ablations were performed in the right auricle from the epicardium before starting extra corporeal circulation, and in the left auricle from the endocardium, while under circulation. Radiofrequency was applied through a surgical multielectrode probe., Results: Eight patients (80%) presented some type of postoperative arrhythmia, with relapse of paroxysmal fibrillation in 3 patients and flutter in another one. At discharge, none of the patients presented relapse of chronic atrial fibrillation. There was no in-hospital mortality. After a mean follow-up of 3 months (range 1-6), 8 patients (80%) have recovered and maintained sinus rhythm. Only one patient has re-established echocardiographic biatrial contraction., Conclusions: Intraoperative radiofrequency has allowed us to perform the auricular lesions, in both auricles, in a simple way, with an initial effectiveness of 80%. Epicardial ablation of the right auricle was simple and safe. Although no patient presented relapse of chronic atrial fibrillation at hospital discharge, postoperative arrhythmias have continued to be the main postsurgical problem.

Background: Atrial fibrillation is frequently observed under conditions associated with atrial dilatation. Atrial size is a factor related to the genesis and maintenance of atrial fibrillation. Predictive parameters of persistence of atrial fibrillation after maze procedure are atrial size and long duration of atrial fibrillation. The aim of this study was to investigate the effects of surgical left atrial reduction in chronic atrial fibrillation by mitral valvulopathy., Patients and Method: nineteen patients with chronic atrial fibrillation and dilated left atrium undergoing mitral valve procedures were included in this prospective study: group I with left atrial reduction (10 patients) and group II including control (9 patients). Both groups were with similar preoperative characteristics., Results: At the mean follow-up of 12 months, all the patients in group II had chronic atrial fibrillation, and 7 patients in group I showed in atrial rhythm (p < 0.003). The patients in whom atrial fibrillation continued after surgery showed left atrial area of 33.8 +/- 12.3 cm2 and a volume of 98.5 +/- 53.9 ml; and the patients with normal rhythm had a left atrial area of 24.5 +/- 5.3 cm2 and a volume 60.3 +/- 21.2 ml., Conclusions: Preliminary results indicate that surgical left atrial reduction in patients with chronic atrial fibrillation may be a mechanism implicated in the elimination of arrhythmia after surgery.

Introduction and Objectives: The late reocclusion or restenosis rate of the infarct related artery is frequent after primary angioplasty. An implanted stent may be able to improve the coronary angioplasty results and long-term outcome of these patients. We present the clinical and angiographic outcome of a cohort of patients treated with primary stenting., Patients and Methods: A group of 74 consecutive patients with acute myocardial infarction treated with primary angioplasty and stenting were followed for one year. An angiographic control was performed at the 6th month of follow-up in 91% of patients to assess the restenosis and reocclusion rates of the infarct-related artery., Results: There were eight in-hospital deaths and three during follow-up (mortality rate 14.8%) and one non-fatal reinfarction (1.5%). The cumulative rate of recurrent ischemia was 6% at 3 months and 15% at 6 months, without any further increment at one-year follow-up. A new angioplasty was performed in 7 patients and three patients underwent surgical revascularization. Thus 80% of patients after discharge were free of events. The angiographic control showed only one reocclusion of the infarct related artery and a restenosis rate of 27%., Conclusions: These results show that primary stenting is an effective procedure in treating non-selected patients with acute myocardial infarction with a low long-term incidence of adverse events and a low restenosis rate.

Currently the insertable loop recorder is usually indicated when the patient has recurrent syncopes and conventional Holter and electrophysiological testing have been negative. We report the case of a patient with dilated cardiomyopathy, admitted to our hospital due to a single episode of syncope. After performing conventional diagnostic procedures, including continuous electrocardiographic monitoring for 48 hours, 24-hour Holter and electrophysiological study, no abnormalities were detected. Therefore, a insertable loop recorder was implanted, which was activated by the patient one month later after a pre-syncopal situation. The Holter reading evidenced self-limited monomorphic ventricular tachycardia, confirming the arrhythmic origin of the syncope. In patients with severe structural heart disease, in whom syncope can be caused by a malignant ventricular arrhythmia, the insertable loop recorder can be indicated in a single episode of syncope when the electrophysiological study is negative.

Introduction and Objectives: There are not any conclusive data about the changes in in-hospital mortality in a non-selected series of patients admitted with acute myocardial infarction in different periods of time. We studied the in-hospital mortality of three extensive series of patients admitted to our Coronary Care Unit during different periods of time, the influence of reperfusion methods and their early application, as well as the changes in baseline characteristics of the three populations studied., Methods: The in-hospital mortality of 1,858 consecutively-admitted patients during three different periods of time (1983-1986, 1992-1994, and 1995-1998) were studied. The demographic data, the previous history and risk factors, the evolution during the acute phase and the treatment prescribed with special attention to the reperfusion methods applied and the delay on its administration were compared., Results: The differences in the baseline characteristics of the populations studied are described. In the two groups of the nineteen-nineties, an increase in the age and in the percentage of women, diabetics and hypertensives was compared. As for the characteristics of acute myocardial infarction, an increase of patients in Killip class 3 and 4 stands out besides other changes. Fibrinolitic treatment decreased during the third period due to the increment in primary angioplasty. There were no significant differences in hospital mortality among the three series studied. The treatment with thrombolysis and primary angioplasty during the first two hours showed a significant independent reduction of mortality., Conclusions: The early application of thrombolysis and primary angioplasty showed an independent reduction of the hospital mortality in our study. Nevertheless the non-adjusted mortality rate did not show any change during the last 15 years.

Antimonial agents are the main drug to treat all forms of leishmaniasis. Meglumine antimoniate is the drug available in Spain and it is usually well tolerated. Nevertheless, this drug frequently alters ventricular repolarization, but few cases of sudden death, presumably related to ventricular arrhythmias, have been reported. We present a case of torsade de pointes during treatment with meglumine antimoniate coexisting with a severe hypokalemia probably due to an acute transitory tubulopathy.

Introduction and Objectives: Stent implantation has been generally contraindicated during primary percutaneous transluminal balloon angioplasty in AMI, because of its possible trombogenicity. Report the early outcome of patients undergoing coronary stenting during primary PTCA., Methods: From january 1995 to april 1996, 31 patients underwent stent implantation in primary. Mean age 62 +/- 11 years. Infarct location was anterior in 20 (65%), and inferior in 11 patients (35%). Four patients were in Killip class IV. Mean onset of chest pain was 129 +/- 29 minutes. Indications for stenting were suboptimal result (64%), dissection (29%) and elective (6%). All patients were treated with heparin during 72 hours and antiplatelet therapy with ticlopidine and aspirin., Results: Coronary stenting restored vessel patency with TIMI 3 flow in 29 patients (94%) and TIMI 2 flow in 2 patients. Angiographic control was performed in 80% of the patients: no stent occlusion was observed and all patients showed a TIMI 3 flow. There were 3 deaths (9%): 2 patients died due to cardiogenic shock and 1 to severe right ventricular dysfunction. 2 patients (6%) had recurrent angina, due to other artery. One patient with left main coronary disease underwent elective coronary artery bypass graft surgery., Conclusions: Intracoronary stent can be used successfully during primary angioplasty with a low incidence of complications. The long term benefits remains to be established.

The improvement of the survival of cardiac patients may cause an impairment of their quality of life. At present, the study of the quality of life of the patients and its changes, must be considered as one of the aims of the Medicine. This study must be comprised clinical, functional, intellectual, social, and labor aspects, and all the items related to the environment of the patient. The first questionnaires used for the study of quality of life were generic but later on, specific questionnaires for different pathologies were found to be preferential. At present, there are questionnaires for hypertensive, myocardial infarction, angina and heart failure patients, and among them the questionnaire for myocardial infarction patients, structures and validated by the authors which has been used to study the quality of life postinfarction patients who followed a cardiac rehabilitation programme.