Denervación renal: Nueva herramienta para tratar la hipertensión arterial esencial resistente

La hipertensión arterial es un problema de salud pública que afecta entre el 30% y el 40% de la población adulta en los países industrializados y a pesar de muchos tratamientos farmacológicos disponibles, la hipertensión en un gran porcentaje de la población permanece sin control. Un porcentaje importante de pacientes con hipertensión sigue siendo resistente a las múltiples combinaciones de drogas, lo que los pone en mayor riesgo de eventos cardiovasculares. La denervación renal con una sonda de radio frecuencia permite la disminución de las fibras aferentes del nervio para reducir así la inervación simpática en estos pacientes. Los pacientes que pueden beneficiarse de esta técnica deben tener una hipertensión esencial no controlada a pesar del tratamiento cuádruple con al menos un diurético tiazidico, y deben tener una tasa de filtración glomerular mayor o igual a 45mL/min. Un primer estudio en la forma de registro demostró por primera vez que la denervación renal es un procedimiento seguro, simple, y permitió una reducción significativa y sostenida de la presión arterial. Entonces, un estudio aleatorio (Symplicity HTN-2) mostró que la presión arterial del grupo que recibió la intervención disminuyó 32/12mmHg promedio, mientras que no se encontró ningún cambio en el grupo de control. Esta disminución de la presión arterial se mantuvo a los 24 meses de seguimiento. No hubo complicaciones relacionadas con el procedimiento, ninguna estenosis de arteria renal o dilatación aneurismática se han identificado durante el seguimiento. Tampoco ha sido observado alteración o empeoramiento de la función renal. Esta técnica parece ser una verdadera esperanza para estos pacientes gravemente enfermos. Presentamos al final de la revisión el protocolo de la sociedad Francesa de Cardiología para la indicación y realización de este novel procedimiento.

Postmyocardial infarction ventricular septal rupture as a potentially fatal complication: when time is the best medicine

International audienc

Thiamine Deficiency as a Cause for Acute Circulatory Failure: An Overlooked Association in Western Countries

International audienceA 42 year-old patient presented with circulatory failure and lactic acidosis. Clinical features, later coupled with biological tests, led to the diagnosis of wet beriberi syndrome and scurvy. Echocardiography showed a pattern of thiamine deficiency with high cardiac output and low vascular resistance. The patient's condition and biological parameters immediately improved after treatment injections of thiamine. Wet BeriBeri is often overlooked in western countries and is a diagnosis that must be considered based on history, and clinical and echocardiographical findings

Comparison of visual scoring and quantitative planimetry methods for estimation of global infarct size on delayed enhanced cardiac MRI and validation with myocardial enzymes

ObjectiveAlthough delayed enhanced CMR has become a reference method for infarct size quantification, there is no ideal method to quantify total infarct size in a routine clinical practice. In a prospective study we compared the performance and post-processing time of a global visual scoring method to standard quantitative planimetry and we compared both methods to the peak values of myocardial biomarkers.Material and MethodsThis study had local ethics committee approval; all patients gave written informed consent. 136 patients admitted with reperfused AMI to our intensive care unit had a complete CMR study with Gadolinium-contrast injection 4±2 days after admission. A global visual score was defined on a 17-segment model and compared with the quntitative planimetric evaluation of hyperenhancement. The peak values of serum troponin I (TnI) and creatine kinase (CK) release were measured in each patient.ResultsThe mean percentage of hyperenhanced myocardium determined by the quantitative planimetry method was (21.3±14.1) with a range of 0-68,6%. There was an excellent correlation between quantitative planimetry and visual global scoring for the hyperenhancement extent's measurement (r=0.91; y=1.04x+3,2; SEE=1.2; P<0.001) The Bland-Altman plot showed a good concordance between the two approaches (mean of the differences = –4.04% with a standard deviation of 6.9).Mean post-processing time for quantitative planimetry was significantly longer than visual scoring post-processing time (23.7± 5.7 minutes VS 5.0±1.1 minutes respectively, P<0.001). Correlation between peak CK and quantitative planimetry was r=0.71 (P<0.001) and r=0.75 (P<0.001) with visual global scoring. Correlation between peak troponin I and quantitative planimetry was r= 0.69 (P<0.001) and r= 0.70 (P<0.001) with visual global scoring.ConclusionA visual approach based on a 17-segment model allows a rapid and accurate assessment of the myocardial global delayed enhancement. This scoring method could be used on a daily practice and useful for the management strategy of post-MI patients

Preliminary experience with Impella Recover\textregistered LP5.0 in nine patients with cardiogenic shock: A new circulatory support system in the intensive cardiac care unit

SummaryAimCardiogenic shock is associated with high mortality. We report our experience with the short-term left ventricular axial pump Impella LP5.0 in nine patients with severe ischaemic heart failure.MethodsSix patients (group 1) presented with cardiogenic shock at the acute phase of an ST elevation myocardial infarction. Three patients (group 2) had severe ischaemic cardiomyopathy with temporary contra-indication to LVAD or transplantation. We measured haemodynamic and metabolic variables up to 96hours and recorded morbidity, mechanical pump failures, and mortality up to one year postimplantation.ResultsIn all patients the Impella LP5.0 was safely placed through the right subclavian artery. Cardiac power output increased from 0.64 (0.07) W to 0.94 (0.44) W and 1.02 (0.30) W at 24 and 72hours, respectively. The Impella LP5.0 remained in place for 12 (7.2) days. In group 1, five patients were in INTERMACS Profile 3 at the time of pump insertion. Three could be weaned and survived. One patient in INTERMACS Profile 1 died of intractable heart failure within hours. In group 2, two of three patients underwent heart transplantation. Haemorrhage requiring transfusions was observed in four patients but only one case was directly related to the Impella LP5.0.ConclusionLeft ventricular assistance with the Impella LP5.0 appears to be well tolerated. It may be especially useful in patients with acute myocardial infarction complicated by cardiogenic shock who achieve INTERMACS Profile 3 with initial treatment