ABSTRACT We describe a 60-year-old woman with post-myocardial infarction (MI) ventricular septal defect (VSD) and cardiogenic shock who was successfully stabilized with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge therapy for the surgical closure of her VSD. This case highlights the role of VA-ECMO in the management of post-MI VSD to improve the results of surgical repair and patient survival.

Abstract Considerable differences exist in the quantification and clinical significance of both supraventricular and ventricular extrasystoles found in Holter recordings. Usually extrasystoles were classified as rare, occasional, frequent and very frequent. Current publications were analyzed regarding the frequency and clinical significance or these arrhythmias, especially in in relation to prior myocardial infarction, ventricular dysfunction, atrial fibrillation and cerebro vascular events. Tables showing limits to define the severity of supraventricular and ventricular extrasystoles are included.

Resumen En la actualidad existen diferencias en la interpretación y cuantificación de los extrasístoles supraventriculares y ventriculares en el Holter de ritmo cardíaco y no existe siempre una misma definición e interpretación de lo que se denomina como “escaso”, “ocasional”, “frecuente” o “muy frecuente”. El objetivo del presente trabajo ha sido revisar las evidencias actuales y sus fundamentos en relación a la cuantificación o carga de la extrasistolía supraventricular y ventricular en un Holter de ritmo cardíaco, lo que debiera contribuir a una mayor precisión y mejor interpretación de la información cuantitativa en la práctica clínica diaria con este examen. Se revisa en la literatura el concepto de carga de extrasístoles supraventriculares y ventriculares y su relación con eventos clínicos: fibrilación auricular y accidente cerebrovascular en el caso de la extrasistolía supraventricular y mortalidad post infarto y deterioro de la función ventricular en el caso de la extrasistolía ventricular. De esta manera se cuantifica en base a la evidencia la extrasistolía supraventricular y ventricular.

Abstracts: Classic renin-angiotensis pathway (RAP) is activated in patients with pulmonary artery hypertension (PAH). We have previously shown that in patients with post myocardial infarction systolic dysfunction the activation of RAP mediated by angiotensin converting enzyme (ACE) and angiotensin II (Ang II) is inversely correlated with the parallel RAP axis mediated by homologous ACE (ACE2) and by the vasoactive and cardioprotective peptide Ang-(1-9). Pre clinical studies show that administration of Ang-(1-9) leads to a favorable ventricular remodelling. At present there is no information regarding levels of Ang-(1-9) in PAH patients compared to healthy subjects. Methods: 16 PAH patients (WHO group 1), with mean PA pressure > 25mmHg being treated with furosemide (40%), Bosentan/Ambrisentan (27%), Sildenafil (80%), iloprost (7%) were compared with healthy subjects (n=14). mPAP, pro BNP, pulmonary vascular resistance (Wu), pulmonary capillary pressure (PCP mmHg), cardiac output (L/min), functional capacity (6 min walking test) (6mWT), and changes in right ventricular fractional area (RV FA), were measured in all subjects. Results: In HAP subjects, the eiotology of PAH was unknown in 87%, or HIV (13%). Functional class was I (6.2 %), II (68.3%) or III (25%). Mean PAP was 51.3±1.9. Compared to healthy subjects, PAH patients had significantly lower RV FA, ACE2 and Ang-(19) levels. Also they had greater ACE plasma activity and AngII circulating levels. Significant correlations were found between Ang-(1-9) and mPAP (-0.701, p < 0,001) and between Ang-(1-9) and RV FA (r = 0.549, p < 0,01). Conclusion: group I PAH subjects, circulating levels of Ang-(1-9) are significantly lower than in healthy subjects and are inversely related to PAP, severity of ventricular remodeling and right ventricular dysfunction. The use of Ang-(1-9) as a vasodilator and cardioprotector agent could be clinically useful in PAH subjects.

Resumen: Introducción: La vía clásica del sistema renina-angiotensina (SRA) está activado en pacientes con hipertensión arterial pulmonar (HAP). Previamente, hemos encontrado que en la disfunción ventricular post infarto al miocardio experimental la activación del eje clásico del SRA, dado por la enzima convertidora de angiotensina I (ECA) y angiotensina (Ang ) II se correlaciona negativamente con el eje paralelo del SRA dado por la ECA homóloga (ECA2) y el péptido vasoactivo y cardioprotector Ang-(1-9). Resultados preclínicos muestran la eficacia de la administración de Ang-(1-9) en el tratamiento del remodelamiento cardiovascular patológico. Hasta la fecha no existen antecedentes de los niveles circulantes de Ang-(1-9) en pacientes con hipertensión arterial pulmonar comparados con sujetos sanos. Objetivo: Determinar los niveles circulantes del péptido vasoactivo y cardiprotector Ang-(1-9) en pacientes con HAP y compararlos con sujetos sanos pareados por edad y sexo. Métodos: Estudio comparativo transversal en pacientes con HAP (grupo I, OMS) con presión de arteria pulmonar media (mPAP) ≥25 mmHg bajo tratamiento con furosemida (40%), espironolactona (53%), Acenocumarol/Warfarina (47%), Bosentan/Ambrisentan (27%), Sildenafil (80%), iloprost (7%) y digoxina (13%). Los sujetos controles correspondieron a sujetos asintomáticos sanos sin enfermedad cardiovascular, cardiopatía estructural ni pulmonar (n=14). En todos los pacientes se determinó mPAP, proBNP, resistencia vascular pulmonar (RVP, WU), presión capilar pulmonar (PCP, mmHg), gasto cardíaco (L/min), capacidad funcional por test de caminata 6 minutos (TC6M), cambio del área fraccional del ventrículo derecho VD (FAC, %). Se utilizó prueba t de Student y programa estadístico SPSS10.0. Un valor de p < 0,05 fue considerado como estadísticamente significativo. Resultados: Los pacientes ingresados al estudio mostraron: etiología de la HAP, idiopática (86,7%), VIH (13,3%), capacidad funcional I (6,2%), II (68,3) y III (25%) y promedio mPAP 51,3±1,9. Pacientes con HAP (grupo I, OMS) versus sujetos sanos mostraron disminución significativa de FAC, actividad plasmática de la ECA2 y niveles circulantes de Ang-(1-9). En la vía clásica del RAAS pacientes con HAP mostraron mayor actividad plasmática de ECA y niveles circulantes e Ag II. Correlaciones significativas se encontraron entre niveles de Ang-(1-9) y mPAP (r = -0.701, p < 0,001) y Ang-(1-9) vs FAC (r = 0.549, p < 0,01). Conclusiones: En pacientes con HAP (grupo I, OMS), los niveles circulantes de Ang-(1-9) están significativamente disminuidos y se asocian inversamente con la PAP, severidad del remodelamiento y disfunción del ventrículo derecho. El uso terapéutico de Ang-(1-9) como agente vasodilatador y cardioprotector podría ser relevante y potencialmente útil, desde una perspectiva clínica, en la HAP. Ang-(1-9) podría reducir la PAP y mejorar el remodelamiento vascular y del ventrículo derecho en la HAP. Por lo tanto, este péptido podría ser útil como blanco terapéutico en la HAP.

Background: Seventy four percent of Chileans replaced the traditional dinner for the consumption of “five o'clock tea” (5CT), a mealtime that includes bread and is simliar to western breakfast. The latter favors the intake of unhealthy foods. Aim: To study whether the consumption of “5CT”, instead of dinner, could be a risk factor for the development of metabolic syndrome (MetSyn). Material and Methods: Anthropometric parameters, mean blood pressure, lipid profile, thyroid stimulating hormone and fasting glucose were measured in 489 subjects aged 39 ± 12 years (33% women) who attended a primary cardiovascular prevention (CV) program. A 24-hour recall and usual meal times were registered during a dietary interview. To determine the association between the consumption of “5CT” or dinner and the probability of presenting two or more components of MetSyn, we built an odds proportional model adjusted by age and sex. In addition, severity for MetSyn was calculated. Results: Nineteen percent of participants had MetSyn and 39%, two or more MetSyn components. Those who consumed “5CT” instead of dinner, had 54% more probability of having 2 or more MetSyn components (Odds ratio = 1.54, confidence intervals 1.032.32, p = 0.04). Participants who included processed carbohydrates in their last meal had a higher probability of having components of MetSyn. This probability decreased among participants who ate dinner with a low proportion of refined carbohydrates. Conclusions: Subjects who eat “5CT”, instead of dinner as the last meal, have a higher cardiometabolic risk and MetSyn severity.

Background: Recently, the American College of Cardiology and American Heart Association (ACC/AHA) proposed a new cardiovascular risk (CV) score. Aim: To evaluate the new risk score (ACC/AHA 2013) in a Chilean population. Material and Methods: Between 2002 and 2014, body mass index (BMI), waist circumference, blood pressure, lipid profile and fasting blood glucose levels were measured and a survey about CV risk factors was responded by 3,284 subjects aged 40 to 79 years (38% females), living in urban Santiago. ACC/AHA 2013, FRAM and Chilean FRAM scores were calculated. All-cause mortality was determined in July 2014 by consulting the Death Registry of the Chilean Identification Service, with an average follow up of 7 ± 3 years. Results: The prevalence of risk factors were 78% for dyslipidemia, 37% for hypertension, 20% for smoking, 7% for diabetes, 20% for obesity and 54% for physical inactivity. The mean FRAM, Chilean FRAM and ACC/AHA scores were 8, 3 and 9%, respectively. During follow-up, 94 participants died and 34 deaths were of cardiovascular cause. Participants who died had a higher prevalence of hypertension (p < 0.01) and diabetes (p < 0. 01) and tended to be older (p = 0.06). The FRAM score for 10 years for deceased and surviving patients was 12 and 8%, respectively (p = NS). The figures for the Chilean FRAM were 5 and 2%, respectively (p = 0.09). The figures for the ACC/AHA 2013 score were 33 and 9%, respectively (p = 0.04). According to receiver operating characteristic curves, ACC/AHA 2013 had a higher area under de curve for CV mortality than FRAM and Chilean FRAM. Conclusions: The new ACC/AHA 2013 score, is better than traditional FRAM and Chilean FRAM scores in predicting cardiovascular mortality in a low risk population.

Background: Pulmonary arterial hypertension (PAH) is a rare and progressive disease. Long-term survival remains poor despite of advances in specific vasodilator therapy. Aim: To describe the survival rate in a cohort of PAH patients in two referral centers in Chile. Patients and Methods: One hundred fifteen patients aged 43 ± 15.6 years (85% females) with PAH qualified for this study. Their median pulmonary artery pressure was 55.4 ± 14 mmHg and their six minutes walking capacity was 368 ± 119 m. They were followed for 58 ± 0.4 months and their actual survival rates were compared with the estimated survival using the equation proposed by the French registry of PAH. Results: One, two and three year survival rates were 97, 94 and 89%, respectively. The observed survival rates were greater than the estimated survival. Conclusions: The improvement in survival rates observed in this cohort of patients is similar to what has been described in literature.

Background: Galectin-3 is a biomarker of myo-cardial fibrosis and has been associated with echocar-diographic markers of right ventricular remodeling in patients with pulmonary artery hypertension (PAH). The association among Galectin-3 level, right atrial (RA) remodeling and functional capacity (FC) has not been explored. The objective was to measure plasma Galectin-3 concentrations and its relation with RA remodeling and FC in PAH patients. Methods: This is a prospective observational study and 14 PAH patients were included. Galectin-3 and proBNP levels were measured in all patients. FC was estimated by the 6-minute walk test (6MWT) and used to define 2 groups of subjects (≤200m or >200m). RA area and volume were measured by echocardiography from a 4 chamber view. Results: The average age was 43±10 years, 84% of patients were female. Galectin-3 levels were 16.1±7.4 ng / mL and 6MWT was 371±142 m. We observed an inverse correlation between RA area and 6MWT (-0.71;p=0.03). Conclusions: Higher Galectin-3 concentrations and RA adverse remodeling are related to a decreased FC in PAH patients. These findings may lead to a better characterization of PAH patients and eventually new therapeutic targets.

Introducción: En pacientes con hipertensión arterial pulmonar (HAP) Galectina- 3, biomarcador de fibrosis miocárdica, se ha asociado a marcadores ecocardiográficos de remodelado ventricular derecho. La relación entre Galectina- 3, remodelado auricular derecho (AD) y capacidad funcional (CF) en pacientes con HAP no ha sido explorado. El objetivo fue medir niveles de Galectina-3 y su relación con CF y remodelado AD en pacientes con HAP Metodos: Estudio prospectivo observacional en que se incluyeron 14 pacientes con HAP En todos los pacientes se midieron los niveles de Galectina-3, proBNP, se evaluó la CF mediante test de caminata 6 minutos (TC6M) y se evaluó remodelado AD. Se consideraron para el análisis dos grupos según la distancia caminada en TC6M (> 200 m vs. ≤ 200 m). Resultados: La edad promedio fue 43 ± 10 años, el 84% mujeres. Los niveles de Galectina-3 fueron 16,1 ± 7,4 ng/mL y el TC6M fue 371 ± 142 mts. Los pacientes con TC6M< 200 m presentaron mayores niveles de Galectina-3 (27,3 ± 4,6 vs 13,7 ± 3,8; p=0,006) y mayor volumen AD (151 ± 21 vs 94 ± 43; p=0,04). Además, se observó una correlación inversa entre el área AD y TC6M (-0,71; p=0,03). Conclusión: Niveles elevados de Galectina-3 y parámetros de remodelado adverso en AD se relacionan con una menor CF en pacientes con HAP. Estos hallazgos apuntan a una mejor caracterización de pacientes con HAP y eventualmente la búsqueda de nuevos objetivos terapéuticos.

A greater use of health resources by adults with congenital heart disease has been reported in international studies. Aim: to describe the use of health resources by adults with CHD in Chile including frequency of medical controls, emergency consultations, hospitalization and medical procedures. Dental consultations and prophylaxis for infective endocarditis were also evaluated Methods: a cross sectional analytic study was per-formed on patients with CHD followed in the Instituto Nacional del Tórax, Santiago, Chile, during 2014 and 2015. Patients were asked to answer a questionnaire and data was analyzed according to gender, and type of CHD (Bethesda classification). Statistics were computed using SPSS. Results: Valid answers were obtained from 363 sub-jects, 180 males (49.6%). Mean age was 20.2 ± 13.3 years. 78 patients (21.5%) had simple, 161 (44.4%) moderate and 124 (34.2%) severe CHD. 296 (84.6%) patients had a medical control within the last year. 151 (41.6%) had attended a medical emergency service > 1 occasion, 76 (20.9% had >= 1 hospitalizations and 54 (14.9%) had been subjected to a medical procedure related to their CHD. Women had more medical controls than males (48,1% vs 35%, p<0,05). 122 (33.6%) had no dental control in the last year and 45% of those attending had no prophylaxis for IE Conclusión: Adults with CHD use health resources including medical visits, hospitalizations and procedures, apparently not all of them related to their CHD. Strategies to optimize use of health resources should be designed. Emphasis on dental controls and prophylaxis for infective endocarditis is needed.

Reportes internacionales han descrito el mayor uso de recursos de salud por parte de los pacientes adultos con cardiopatía congénita (CC). Objetivo: Describir el uso de recursos de salud por parte de esta población en términos de frecuencia de controles médicos, consultas a servicio de urgencia, hospitalizaciones y procedimientos realizados. También se buscó explorar la frecuencia de control odontológico y la indicación de profilaxis de endocarditis como una medida de calidad de atención. Metodología: Se realizó un estudio cuantitativo de corte transversal, analítico e individual en pacientes controlados en el Instituto Nacional del Tórax, durante el período 2014-2015. Los pacientes respondieron una encuesta en forma autónoma. Se realizó análisis por grupos según sexo y tipo de CC según el consenso de Bethesda (simple, moderada o compleja). El análisis estadístico se realizó a través del programa SPSS. Resultados: Se recolectaron 363 encuestas válidas que correspondieron a 180 hombres (49,6%) y con una edad promedio de 29,2±13,3 años. Según el tipo de CC: simple 78 pacientes (21,5%), moderada 161 (44,4%) y compleja 124 (34,2%). 296 pacientes (84,6%) tuvieron el último control médico hace menos de un año. 151 pacientes (41,6%) han consultado una o más veces al servicio de urgencia. 76 pacientes (20,9%) han sido hospitalizados una o más veces y 54 pacientes (14,9%) se han realizado uno o más procedimientos en el último año. En el análisis por tipo de CC no se encontraron diferencias significativas en ninguno de los parámetros evaluados. En el análisis según sexo, se observó que las mujeres consultan más al servicio de urgencia que los hombres (48,1% vs 35%, p<0,05). En cuanto a salud oral, 122 pacientes (33,6%) no ha realizado un control odontológico hace más de 1 año y de aquellos pacientes que asistieron al dentista, 165 de ellos (45,5%) no recibió profilaxis antibiótica para endocarditis en su última atención. Conclusiones: Los adultos con CC reportan una demanda de recursos de salud expresada en controles médicos, consultas de urgencia, hospitalizaciones y procedimientos, que aparentemente no es sólo por factores relacionados a sus patologías. Es necesario elaborar estrategias de atención en salud para responder a las necesidades de esta creciente población y que permitan un uso razonable de recursos. Es perentorio estimular el control periódico dental y la profilaxis de endocarditis.

Factors associated with therapeutic lifestyle change (TLC) after myocardial infarction (MI) have not been fully investigated in Chile. This study aimed to provide a descriptive examination of facilitators and barriers to TLC after first MI. Methods: Qualitative study based on in-depth interviews and focus groups with cardiologists and patients who had first MI one-year±2 months before the begin-ning of the study. Grounded theory research methods were used to guide sampling and coding of data. Results: Twenty-one patients who had first myocardial infarction and 14 cardiologists participated in in-depth interviews and focus groups until the point of theoretical saturation. Facilitators for TLC included optimism, self-efficacy, faith-based life purpose, positive attitudes by family and friends, social participation, good patient-physician relationship, and positive medical advice. Barriers were: individual (older age, female sex, lower educational level, limiting beliefs, ambi val ence, depressive mood, lack of knowledge on strategies to achieve TLC, financial constraints), family (family crisis, overprotection, im-posing attitudes, unhealthy habits at home), work (work overload and competition between work recovery and TLC), socio-environmental (neighborhood unsafety), and health provider-related (poor patient-physician re-lationship, limiting beliefs among physicians, medical advice centered on restrictions or imprecise, medical training focused on pharmacological therapies and in-terventional procedures over preventive care, and orga-nizational issues). Conclusions: Reported facilitators and barriers enhance understanding of the process of lifestyle change after first myocardial infarction, and might be targets for optimization of secondary preventive strategies among Chilean patients.

Los factores asociados con el cambio terapéutico de estilos de vida (TLC) después de un infarto agudo al miocardio (IAM) no han sido suficientemente investigados en Chile. El objetivo de este estudio fue explorar y describir los facilitadores y barreras para la adopción de TLC en pacientes que han sufrido un primer IAM. Métodos: Estudio cualitativo basado en entrevistas en profundidad y grupos focales con cardiólogos y pacientes que tuvieron un primer IAM un año ± 2 meses antes del inicio del estudio. Se usó metodología de Teoría Fundada para guiar el muestreo y la codificación de los datos. Resultados: Veintiún pacientes con un primer IAM y 14 cardiólogos participaron en las entrevistas en profundidad y grupos focales, hasta el punto de saturación teórica. Facilitadores para TLC incluyeron optimismo, autoeficacia, propósito de vida basado en la fe, actitudes positivas por familiares y amigos, participación social, buena relación médico-paciente, y un consejo médico positivo. Las barreras fueron: individuales (edad avanzada, sexo femenino, bajo nivel educacional, creencias limitantes entre los pacientes, ambivalencia, estado de ánimo depresivo, falta de conocimiento sobre estrategias para lograr TLC, limitaciones financieras), a nivel familiar (crisis de la familia, sobreprotección, imposición de actitudes, hábitos no saludables en el hogar), a nivel laboral (sobrecarga de trabajo y competencia entre la recuperación del trabajo y la adopción de TLC), a nivel socio-ambiental (inseguridad del barrio), y a nivel del proveedor de salud (mala relación médico-paciente, creencias limitantes entre los médicos, consejo médico impreciso o basado en restricciones, formación médica centrada en aspectos farmacológicos e intervencionales por sobre lo preventivo, y problemas de organización). Conclusiones: Los facilitadores y barreras reportados mejoran la comprensión del proceso de cambio de estilos de vida después del primer infarto agudo al miocardio, y pueden contribuir a la optimización de estrategias de prevención cardiovascular secundaria en pacientes chilenos.

Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42-year-old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who presented with an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilator therapy. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully controlled with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a life saving and useful approach in this condition.

Abstract: The clinical case of an asymptomatic 25 year old woman whose echocardiogram showed a patent ductus arteriosus is presented. The pathophysiology and management are discussed

Resumen: Se presenta el caso clínico de una mujer de 25 años asintomática en cuyo ecocardiograma se descubre la presencia de un Ductus Arterioso persistente. Se analiza la fisiopatología y el manejo de esta situación.

It is unknown why heart failure progresses even when patients are treated with the best therapy available. Evidences suggest that heart failure progression is due to loss of neurohumoral blockade in advanced stages of the disease and to alterations in myocardial metabolism induced, in part, by this neurohumoral activation. Alterations in cardiac energy metabolism, especially those related to substrate utilization and insulin resistance, reduce the efficiency of energy production, causing a heart energy reserve deficit. These events play a basic role in heart failure progression. Therefore, modulation of cardiac metabolism has arisen as a promissory therapy in the treatment of heart failure. This review describes myocardial energy metabolism, evaluates the role of impaired energy metabolism in heart failure progression and describes new therapies for heart failure involving metabolic intervention.