Manejo de la hipertensión pulmonar tromboembólica crónica: nuevas líneas de trabajo

La hipertensión pulmonar tromboembólica crónica es una patología rara que consiste en una enfermedad vascular pulmonar progresiva. El tromboembolismo pulmonar, no resuelto completamente, es su causa más frecuente; la oclusión crónica del árbol vascular pulmonar conduce a insuficiencia respiratoria y cardiaca. El pronóstico sin tratamiento es nefasto; con una supervivencia del 30% a los 5 años cuando la presión media en arteria pulmonar es mayor de 40 mmHg. El tratamiento de elección y potencialmente curativo es la cirugía de tromboendartetectomía pulmonar. El procedimiento ha demostrado ser seguro y eficaz; en la mayoría de los pacientes intervenidos desaparecen los síntomas y se normalizan los parámetros hemodinámicos. Este tratamiento puede indicarse en, al menos, un 60% de los pacientes con hipertensión pulmonar tromboembólica crónica. La alternativa terapéutica para los pacientes inoperables ha sido, hasta hace poco, el tratamiento médico específico para hipertensión pulmonar, sustentando su uso en la eficacia demostrada en otros tipos de hipertensión pulmonar..

Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension: the Spanish experience

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) can be cured by pulmonary endarterectomy (PEA). It is considered the best and only curable treatment option for patients with accessible lesions evaluated as optimal candidates. We describe the experience of the two reference centers in Spain, in order to reinforce the need for referring CTEPH patients to a specialized center to be assessed by a Multidisciplinary Expert Team. Methods: We included a population of 338 patients who met the definition for CTEPH and underwent PEA between January 2007 and December 2019. The surgery was indicated in almost 60% of patients assessed. Demographic, anthropometric, hemodynamic and echocardiographic features are listed for PEA patients. Immediate and one-year postoperative outcomes as well as overall mortality were analyzed. Results: Mean age was 53.5±15.0 years, 53.8% were men; a total of 68.5% were in WHO functional class III-IV; and most of them were in a preoperative hemodynamic condition: mean pulmonary arterial pressure (mPAP) was 46.5±13.1 mmHg and mean pulmonary vascular resistance (PVR) was 764.5±392.8 dyn·s·cm-5. PEA surgery was performed with cardiopulmonary bypass (CBP) and circulatory arrest, with very few complications [including neurological, postoperative reperfusion edema, extracorporeal membrane oxygenation (ECMO) implant and cardiac failure] and optimal postoperative results, where exercise capacity increased and mPAP and PVR values decreased significantly. Presence of persistent pulmonary hypertension (PH) at the six-month right heart catheterization was evaluated. A 3.3% perioperative mortality was achieved. Overall, one-, three- and five-year survival rates were analyzed by Kaplan-Meier's method (94.8%, 93.3% and 90.5% respectively), as well as for residual PH patients. Mortality risk factors were assessed. Conclusions: Outstanding PEA results were seen in the immediate, one-year and long-term outcomes. The incidence of complications, including in-hospital mortality and long-term mortality were also below European rates

Glycemic Variability and Its Association With Demographics and Lifestyles in a General Adult Population

Objective: The objective was to investigate glycemic variability indices in relation to demographic factors and common environmental lifestyles in a general adult population. Methods: The A Estrada Glycation and Inflammation Study is a cross-sectional study covering 1516 participants selected by sampling of the population aged 18 years and over. A subsample of 622 individuals participated in the Glycation project, which included continuous glucose monitoring procedures. Five glycemic variability indices were analyzed, that is, SD, MAGE, MAG, CONGA1, and MODD. Results: Participants had a mean age of 48 years, 62% were females, and 12% had been previously diagnosed with diabetes. In the population without diabetes, index distributions were not normal but skewed to the right. Distributional regression models that adjusted for age, gender, BMI, alcohol intake, smoking status, and physical activity confirmed that all indices were positively and independently associated with fasting glucose levels and negatively with heavy drinking. SD, MAGE, and CONGA1 were positively associated with aging, and MAG was negatively associated with BMI. None of the GVI studied were influenced by physical activity. Age-group-specific reference values are given for the indices. Conclusions: This study yielded age-specific reference values for glucose variability indices in a general adult population. Significant increases were observed with aging. Heavy drinking of more than 140 g/week was associated with significant decreases in variability indices. No differences were found between males and females. These normative ranges provide a guide for clinical care, and may offer an alternative treatment target among persons with diabetesThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was supported by grants from Spain’s Carlos III Institute of Health (Instituto de Salud Carlos III/ISCIII) (PI11/02219 & PI13/02594) and the European Regional Development Fund (FEDER). PDV and MAS were supported by ISCIII Preventive Activity & Health Promotion Research Network (Red de Investigación en Actividades Preventivas y de Promoción de Salud/redIAPP) grants RD06/0018/0006 & RD12/0005/0007, respectively. CCS has been partially supported by the Spanish Ministry of Science and Innovation (MTM2015-69068-REDT)S

Impacto de la COVID-19 en los servicios de cirugía cardiovascular en España: Análisis de los grupos relacionados con el diagnóstico (Estudio SECCE-COVID-19 fase 2)

Introducción y objetivos La pandemia por COVID-19 causada por infección del virus SARS-CoV-2 ha saturado al sistema sanitario español, afectándose la atención de las enfermedades cardiovasculares. Queremos cuantificar el impacto de la pandemia en el número de las intervenciones quirúrgicas cardíacas analizando los grupos relacionados con el diagnóstico (GRD) más prevalentes de nuestra especialidad. Métodos A instancias de la Sociedad Española de Cirugía Cardiovascular y Endovascular, se solicitó a todos los centros nacionales que quisieron participar, los datos de los códigos de GRD números 162 (cirugía sobre válvulas cardíacas con infarto o diagnóstico complejo), 163 (cirugía sobre válvulas cardíacas sin infarto o diagnóstico complejo), 165 (bypass coronario con infarto o diagnóstico complejo), 166 (bypass coronario sin infarto o diagnóstico complejo) y 167 (otros procedimientos cardiotorácicos o vasculares torácicos) entre el 1 de marzo de 2020 y el 30 de septiembre de 2020 (siete meses), y como período control las mismas fechas de 2019. Resultados Se recibieron los datos de 24 hospitales, 22 públicos y dos privados. Existió un descenso global en el número de intervenciones del 30% (rango -19 a -42%, p < 0,001) de 4.648 en 2019 a 3.262 en 2020 (-1.386 de diferencia), siendo +7% para el GRD 162 (p = 0,500), -37% para el 163 (p = 0,001), -9% para el 165 (p = 0,304), -32% para el 166 (p = 0,001), y -16% para el 167 (p = 0,062). Conclusiones Existió un descenso global de cirugías estadísticamente significativo en 2020 del 30% respecto del 2019 entre el 1 de marzo y el 30 de septiembre

Análisis de coste-utilidad del manejo de la fibrilación auricular concomitante en España Cost-utility analysis of concomitant atrial fibrillation management in Spain

Objetivos: La fibrilación auricular (FA) es la arritmia más común en la práctica clínica; es un factor de riesgo de accidente cerebrovascular (ACV), y está asociada a una importante morbilidad y mortalidad. Nuestro objetivo fue realizar un análisis de coste-utilidad de las diferentes opciones de tratamiento en pacientes >40 años con FA concomitante con valvulopatía mitral en España, desde la perspectiva del Sistema Nacional de Salud. Métodos: Se realizó una evaluación económica mediante un modelo de Markov con cuatro estados de salud (ritmo sinusal, FA, ACV dependiente, muerte) simulando una cohorte de 1.000 pacientes en cada opción de tratamiento más cirugía de válvula mitral (tratamiento farmacológico, ablación quirúrgica y ablación por catéter). El horizonte temporal fue de 5 años, con ciclos de 3 meses. Los datos de costes y efectos se obtuvieron de la revisión de la literatura y de la opinión de expertos clínicos, descontados al 3,5% anual. Se realizó un análisis de sensibilidad probabilístico para determinar la robustez de nuestros resultados. Resultados: Los años de vida ajustados por calidad (AVAC) ganados fueron 3,29, 3,89 y 3,83, respectivamente, para las alternativas de no ablación, ablación quirúrgica y ablación por catéter. Los costes por paciente fueron de 5.770€, 10.034€ y 11.289€, respectivamente. La razón coste/AVAC de ablación quirúrgica frente a no ablación fue de 7.145€. La ablación quirúrgica resultó dominante frente a la ablación por catéter. El análisis probabilístico de sensibilidad mostró que los resultados del modelo fueron robustos. Conclusiones: La ablación quirúrgica es una opción de tratamiento coste-efectiva en los pacientes con FA concomitante, con una razón coste-efectividad por debajo del umbral de eficiencia comúnmente aceptado en España.<br>Objectives: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice; this disorder is a risk factor for stroke and is associated with substantial morbidity and mortality. Our objective was to develop a cost-utility analysis of the different treatment alternatives in patients aged 40 years old or more with concomitant AF with valve disease in Spain, from the National Health System perspective. Methods: An economic evaluation through a Markov model with four health states (sinus rhythm, AF, dependent stroke, death) was developed to simulate the evolution of a cohort of 1,000 patients receiving each treatment alternative in addition to mitral valve surgery (drug therapy, surgical ablation and catheter ablation). The time horizon was 5 years, with a cycle length of 3 months. Data on costs and effects were obtained from the published literature and expert opinion and were discounted at 3.5%. A sensitivity analysis was developed to determine the robustness of the results. Results: The quality-adjusted life years (QALY) gained were 3.29, 3.89, and 3.83, respectively, for the alternatives of no ablation, surgical ablation and catheter ablation. The costs per patient were 5,770€, 10,034€ and 11,289€, respectively. The surgical ablation cost/QALY rate compared with no ablation was 7,145€. Surgical ablation was dominant versus catheter ablation. The probabilistic sensitivity analysis showed that the results were robust. Conclusions: Surgical ablation is a cost-effective treatment option in patients with concomitant AF, with a cost-effectiveness ratio under the efficiency threshold commonly accepted in Spain

SARS-CoV-2 in Conjunctiva and Tears and Ocular Symptoms of Patients with COVID-19

This study investigates the presence of SARS-CoV-2 in conjunctival secretions and tears and evaluates ocular symptoms in a group of patients with COVID-19. We included 56 hospitalized patients with COVID-19 in this cross-sectional cohort study. Conjunctival secretions and tears were collected using flocked swabs and Schirmer strips for SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR). Assessment of ocular surface manifestations included an OSDI (Ocular Surface Disease Index) questionnaire. Patients had been admitted to hospital for an average of 2.4 days (range 0–7) and had shown general symptoms for an average of 7.1 days (range 1–20) prior to ocular testing. Four (7.1%) of 56 conjunctival swabs and four (4%) of 112 Schirmer strips were positive for SARS-CoV-2. The mean E-gene cycle threshold values (Ct values) were 31.2 (SD 5.0) in conjunctival swabs and 32.9 (SD 2.7) in left eye Schirmer strips. Overall, 17 (30%) patients presented ocular symptoms. No association was found between positive ocular samples and ocular symptoms. This study shows that SARS-CoV-2 can be detected on the conjunctiva and tears of patients with COVID-19. Contact with the ocular surface may transmit the virus and preventive measures should be taken in this direction